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 |
| HSA Seed Money | Individual/Family |
| Band 1: Less than $45,000 | $800/$1,600 |
| Band 2: $45,000.01 - $60,000 | $600/$1,200 |
| Band 3: $60,000.01 - $90,000 | $400/$800 |
| Band 4: Over $90,000 | $200/$400 |
| Coinsurance | |
| Percentage | 90% |
| Services | |
| Preventive Care | Covered at 100% |
| Office Visit | Deductible and Coinsurance |
| Specialist Visit | Deductible and Coinsurance |
| Urgent Care | Deductible and Coinsurance |
| Emergency Room (Waived if admitted) | Deductible and Coinsurance |
| Pharmacy | |
| Retail (30-day supply) | |
| Generic Drugs | 10% coinsurance |
| Formulary Brand Drugs | 20% coinsurance |
| Non-Formulary Brand Drugs | 40% coinsurance |
| Mail Order | |
| Generic Drugs | 10% coinsurance |
| Formulary Brand Drugs | 20% coinsurance |
| Non-Formulary Brand Drugs | 40% coinsurance |
| Specialty | |
| Formulary Drugs | 20% and $65 Minimum |
| Non-Formulary Brand Drugs | 40% and $100 Minimum |
| Out-of-Pocket Maximum | Integrated with Medical |
For more details, see the overview of coverage grid.