2019 PPO Plan Coverage

2019 PPO Plan Coverage - Faculty & Staff
Deductible
Salary Range <$45,000 $45,001 - $60,000 $60,001 - $90,000 >$90,000
Individual $250 $375 $500 $625
Family $500 $750 $1,000 $1,250
Coinsurance Out-of-Pocket Maximum
Individual $1,250
Family $2,500
Total Out-of-Pocket Maximum (*See note at end of table)
Individual $7,150
Family $14,300
Member Coinsurance (after deductible)
Percentage 10%
Services
Preventive Care Covered at 100%
Office Visit $20 copay
Specialist Visit $30 copay
Urgent Care $30 copay
Emergency Room (waived if admitted) $100 copay
Pharmacy
Retail (30-day supply)
Generic Drugs 50% Coinsurance
Formulary Brand Drugs 50% Coinsurance
Non-Formulary Brand Drugs 70% Coinsurance
Mail Order (90-day supply)
Generic Drugs 20% Coinsurance
Formulary Brand Drugs 20% Coinsurance
Non-Formulary Brand Drugs 70% Coinsurance
Specialty
Formulary Brand Drugs 50% Coinsurance and $50 Maximum
Non-Formulary Brand Drugs 70% Coinsurance and $100 Maximum
Out-of-Pocket Maximum $2,000/$8,000

* Total Maximum Out-of-Pocket Maximum (TMOOP) is mandated by the federal government effective with plan years beginning on or after January 1, 2014. TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical expense. With plan years beginning on or after January 1, 2019, TMOOP cannot be more than $7,150 for an individual and $14,300 for plans with two or more persons. Your plan satisfies this requirement.

 

2019 PPO Plan Coverage - Technical Service
Deductible
Individual $250
Parent/Child(ren) $375
Family $500
Coinsurance Out-of-Pocket Maximum
Individual $1,250
Parent/Child(ren) $1,875
Family $2,500
Total Out-of-Pocket Maximum (* See note at end of table)
Individual $7,150
Parent/Child(ren) $14,300
Family $14,300
Member Coinsurance
Perentage 10%
Services
Preventive Care Covered at 100%
Office Visit $10 copay
Specialist Visit $20 copay
Urgent Care $20 copay
Emergency Room (waived if admitted) $100 copay
Pharmacy
Retail (30-day supply)
Generic Drugs 50% Coinsurance
Formulary Brand Drugs 50% Coinsurance
Non-Formulary Brand Drugs 70% Coinsurance
Mail Order (90-day supply)
Generic Drugs 20% Coinsurance
Formulary Brand Drugs 20% Coinsurance
Non-Formulary Brand Drugs 70% Coinsurance
Specialty
Formulary Brand Drugs 50% Coinsurance and $50 Maximum
Non-Formulary Brand Drugs 70% Coinsurance and $100 Maximum
Out-of-Pocket Maximum $1,000/$6,000

* Total Maximum Out-of-Pocket Maximum (TMOOP) is mandated by the federal government effective with plan years beginning on or after January 1, 2014. TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical expense. With plan years beginning on or after January 1, 2019, TMOOP cannot be more than $7,150 for an individual and $14,300 for plans with two or more persons. Your plan satisfies this requirement.

 

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

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