Overview of Coverage - PPO Savings Plan
| Deductible | |
|---|---|
| Individual | $1,600 |
| Family | $3,200 |
| Coinsurance Out-of-Pocket Maximum | |
| Individual | $1,975 |
| Family | $3,950 |
| Total Out-of-Pocket Maximum | |
| Individual | $3,575 |
| Family | $7,150 |
| Member Coinsurance (after deductible) | |
| Percentage | 10% |
| Services | |
| Preventive Care | Covered at 100% |
| Office Visits | Deductible and Coinsurance |
| Specialist | Deductible and Coinsurance |
| Urgent Care | Deductible and Coinsurance |
| Emergency Room (waived if admitted) | Deductible and Coinsurance |
| Prescription (after deductible) | |
| Retail (30-day supply) | |
| Generic Medications | 10% Coinsurance |
| Formulary Brand Medications | 20% Coinsurance |
| Non-Formulary Brand Medications | 40% Coinsurance |
| Mail (90-day supply) | |
| Generic Medications | 10% Coinsurance |
| Formulary Brand Medications | 20% Coinsurance |
| Non-Formulary Brand Medications | 40% Coinsurance |
| Specialty Medications | |
| Formulary Drugs | 20% and $65 Minimum |
| Non-Formulary Brand Medications | 40% and $100 Maximum |
| Out-of-Pocket Maximums | Integrated with Medical |
To help calculate the costs for your medications, use the pharmacy pricing tools below:
- PPO Savings Plan Pharmacy Pricing Tool (Before Deductible is Met)
- PPO Savings Plan Pharmacy Pricing Tool (After Deductible is Met)
Documents
- 2019 PPO Savings Plan Overview of Coverage Grid
- 2019 PPO Savings Plan Schedule of Benefits
- 2019 Technical Service PPO Savings Plan Summary of Benefits Coverage
- 2019 Faculty & Staff PPO Savings Plan Summary of Benefits Coverage