Overview of Coverage - PPO Savings Plan

2018 PPO Savings Plan Faculty, Staff, and Technical Service Employees
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.