Overview of Coverage - PPO Savings Plan

PPO Savings Plan - Coverage
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 Drugs 10% Coinsurance
Preferred Brand Drugs 20% Coinsurance
Non-Preferred Brand Drugs 40% Coinsurance
Mail (90-day supply)
Generic Drugs 10% Coinsurance
Preferred Brand Drugs 20% Coinsurance
Non-Preferred Brand Drugs 40% Coinsurance
Specialty Medications
Preferred Brand Drugs 20% coinsurance, $65 Minimum
Non-Preferred Brand Medications 40% coinsurance, $100 Minimum
Out-of-Pocket Maximums Integrated with Medical
New Preventive Drug List - 2020
* NO DEDUCTIBLE, COINSURANCE ONLY
Preventive Drug List
Generic Drugs 10% coinsurance
Preferred Brand Drugs 20% coinsurance
Non-Preferred Brand Drugs 40 % coinsurance

To help calculate the costs for your medications, use the pharmacy pricing tools below:

Documents