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 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 |
| * 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:
- PPO Savings Plan Pharmacy Pricing Tool (Before Deductible is Met)
- PPO Savings Plan Pharmacy Pricing Tool (After Deductible is Met)
Documents
- 2020 PPO Savings Plan Schedule of Benefits
- 2020 PPO Savings Overview of Coverage
- 2020 Summary of Benefits Coverage - Technical Service
- 2020 Summary of Benefits Coverage - Faculty and Staff