2023 Lion Traditional (formerly PPO plan)

2023 Lion Traditional (formerly PPO plan) Coverage - Faculty & Staff
Deductible
Salary Range	< = $45,000	$45,001 - $60,000	$60,001 - $90,000	> $90,000
Individual	$250	$375	$500	$625
Family	$500	$750	$1,000	$1,250
Coinsurance Maximum
Individual	$1,250
Family	$2,500
Member Coinsurance (after deductible)
Percentage	10%
Services
Preventive Care Highmark Preventive Schedule	Covered at 100%
Office Visit	$20 copay
Specialist Visit	$30 copay
Urgent Care	$30 copay
Emergency Room (waived if admitted)	$100 copay
Faculty & Staff Prescription $2,000 Individual / $8,000 Family Prescription out-of-pocket maximum
Preventive Drugs
Generic Drugs	10% Coinsurance
Preferred Brand Drugs	20% Coinsurance
Non-Preferred Brand Drugs	40% Coinsurance
Retail (30-day supply)
Generic Drugs	50% Coinsurance
Preferred Brand Drugs	50% Coinsurance
Non-Preferred Brand Drugs	70% Coinsurance
Mail order
Generic Drugs	20% Coinsurance
Preferred Brand Drugs	20% Coinsurance
Non-Preferred Brand Drugs	70% Coinsurance
Specialty Medications
Preferred Brand Drugs	50% Coinsurance, $50 Maximum
Non-Preferred Brand Drugs	70% Coinsurance, $100 Maximum

2023 Lion Traditional Coverage - Technical Service
Deductible
Individual	$250
Parent/Child(ren)	$375
Family	$500
Coinsurance Maximum
Individual	$750
Parent/Child(ren)	$1,125
Family	$1,500
Member Coinsurance
Perentage	10%
Services
Preventive Care	Covered at 100%
Office Visit	$10 copay
Specialist Visit	$20 copay
Urgent Care	$20 copay
Emergency Room (waived if admitted)	$100 copay

Technical Service Prescription $1,000 Individual / $6,000 Family prescription out-of-pocket maximum
Preventive Drugs
Generic Drugs	10% Coinsurance
Preferred Brand Drugs	20% Coinsurance
Non-Preferred Brand Drugs	40% Coinsurance
Retail (30-day supply)
Generic Drugs	50% Coinsurance
Preferred Brand Drugs	50% Coinsurance
Non-Preferred Brand Drugs	70% Coinsurance
Mail Order (90-day supply)
Generic Drugs	20% Coinsurance
Preferred Brand Drugs	20% Coinsurance
Non-Preferred Brand Drugs	70% Coinsurance
Specialty
Preferred Brand Drugs	50% Coinsurance, $50 Maximum
Non-Preferred Brand Drugs	70% Coinsurance, $100 Maximum