PPO Plan
The PPO Plan is a traditional PPO plan. It has a lower deductible and a higher payroll deduction than the PPO Savings Plan.
Following are some features of the PPO Plan:
- Medical coverage is the same as for the PPO Savings Plan
- Physician network is the same as for the PPO Savings Plan
- Drug formulary is that same as for the PPO Savings Plan
- Includes an optional Medical Flexible Spending Account that allows subscribers to use pre-tax funds to pay for health care expenses incurred during the current plan year
Faculty & Staff Monthly Premiums
| Coverage | Salary % | $30,000 | $40,000 | $50,000 | $60,000 | $75,000 | $85,000 | $100,000 | $140,000 |
|---|---|---|---|---|---|---|---|---|---|
| Individual | 1.51% | $37.75 | $50.33 | $62.92 | $75.50 | $94.38 | $106.96 | $125.83 | $176.17 |
| Two-Person | 3.68% | $92.00 | $122.67 | $153.33 | $184.00 | $230.00 | $260.67 | $306.67 | $429.33 |
| Parent/Child(ren) | 3.41% | $85.25 | $113.67 | $142.08 | $170.50 | $213.13 | $241.54 | $284.17 | $397.83 |
| Family | 4.69% | $117.25 | $156.33 | $195.42 | $234.50 | $293.13 | $332.21 | $390.83 | $547.17 |
Technical Service Premiums
| Coverage | Salary % | $30,000 | $40,000 | $50,000 | $60,000 | $75,000 | $85,000 | $100,000 | $140,000 |
|---|---|---|---|---|---|---|---|---|---|
| Individual | 2.71% | $31.27 | $41.69 | $52.12 | $62.54 | $78.17 | $88.60 | $104.23 | $145.92 |
| Two-Person | 5.86% | $67.62 | $90.15 | $112.69 | $135.23 | $169.04 | $191.58 | $225.38 | $315.54 |
| Parent/Child(ren) | 5.47% | $63.12 | $84.15 | $105.19 | $126.23 | $157.79 | $178.83 | $210.38 | $294.54 |
| Family | 7.35% | $84.81 | $113.08 | $141.35 | $169.62 | $212.02 | $240.29 | $282.69 | $395.77 |
| 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 Out-of-Pocket Maximum | ||||
| Individual | $1,250 | |||
| Family | $2,500 | |||
| Total Out-of-Pocket Maximum (*See note at end of table) | ||||
| Individual | $7,150 | |||
| Family | $14,300 | |||
| Member Coinsurance (after deductible) | ||||
| Percentage | 10% | |||
| Services | ||||
| Preventive Care | Covered at 100% | |||
| Office Visit | $20 copay | |||
| Specialist Visit | $30 copay | |||
| Urgent Care | $30 copay | |||
| Emergency Room (waived if admitted) | $100 copay | |||
| Pharmacy | ||||
| Retail (30-day supply) | ||||
| Generic Drugs | 50% Coinsurance | |||
| Formulary Brand Drugs | 50% Coinsurance | |||
| Non-Formulary Brand Drugs | 70% Coinsurance | |||
| Mail Order (90-day supply) | ||||
| Generic Drugs | 20% Coinsurance | |||
| Formulary Brand Drugs | 20% Coinsurance | |||
| Non-Formulary Brand Drugs | 70% Coinsurance | |||
| Specialty | ||||
| Formulary Brand Drugs | 50% Coinsurance and $50 Maximum | |||
| Non-Formulary Brand Drugs | 70% Coinsurance and $100 Maximum | |||
| Out-of-Pocket Maximum | $2,000/$8,000 | |||
* Total Maximum Out-of-Pocket Maximum (TMOOP) is mandated by the federal government effective with plan years beginning on or after January 1, 2014. TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical expense. With plan years beginning on or after January 1, 2019, TMOOP cannot be more than $7,150 for an individual and $14,300 for plans with two or more persons. Your plan satisfies this requirement.
| Deductible | ||||
|---|---|---|---|---|
| Individual | $250 | |||
| Parent/Child(ren) | $375 | |||
| Family | $500 | |||
| Coinsurance Out-of-Pocket Maximum | ||||
| Individual | $1,250 | |||
| Parent/Child(ren) | $1,875 | |||
| Family | $2,500 | |||
| Total Out-of-Pocket Maximum (* See note at end of table) | ||||
| Individual | $7,150 | |||
| Parent/Child(ren) | $14,300 | |||
| Family | $14,300 | |||
| 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 | |||
| Pharmacy | ||||
| Retail (30-day supply) | ||||
| Generic Drugs | 50% Coinsurance | |||
| Formulary Brand Drugs | 50% Coinsurance | |||
| Non-Formulary Brand Drugs | 70% Coinsurance | |||
| Mail Order (90-day supply) | ||||
| Generic Drugs | 20% Coinsurance | |||
| Formulary Brand Drugs | 20% Coinsurance | |||
| Non-Formulary Brand Drugs | 70% Coinsurance | |||
| Specialty | ||||
| Formulary Brand Drugs | 50% Coinsurance and $50 Maximum | |||
| Non-Formulary Brand Drugs | 70% Coinsurance and $100 Maximum | |||
| Out-of-Pocket Maximum | $1,000/$6,000 | |||
* Total Maximum Out-of-Pocket Maximum (TMOOP) is mandated by the federal government effective with plan years beginning on or after January 1, 2014. TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical expense. With plan years beginning on or after January 1, 2019, TMOOP cannot be more than $7,150 for an individual and $14,300 for plans with two or more persons. Your plan satisfies this requirement.
To help calculate the costs for your medications, use the pharmacy pricing tools below:
Documents
- Aetna Health Insurance Book
- 2019 PPO Plan Technical Services Overview of Coverage Grid
- 2019 PPO Plan Faculty & Staff Overview of Coverage Grid
- 2019 PPO Plan Schedule of Benefits
- 2019 Technical Services PPO Plan Summary of Benefits Coverage
- 2019 Faculty & Staff PPO Plan Summary of Benefits Coverage – Salary: Under $45,000
- 2019 Faculty & Staff PPO Plan Summary of Benefits Coverage – Salary: $45,001-$60,000
- 2019 Faculty & Staff PPO Plan Summary of Benefits Coverage – Salary: $60,001-$90,000
- 2019 Faculty & Staff PPO Plan Summary of Benefits Coverage – Salary: Above $90,000