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
COVID-19 Testing: Aetna is waiving all cost sharing for diagnostic testing related to COVID-19, including serological (anti-body) tests. This includes deductibles, copays, and coinsurance. Aenta will also waive cost sharing on the associated provider, urgent care center, or emergency room visit that resulted in an order for or administration of the test. Under federal law, this waiver will remain in place for so long as the federal emergency remains in effect.
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

Preventive Drug List
* 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: