2019 PPO Savings Plan Coverage

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 Medications 10% Coinsurance
Formulary Brand Medications 20% Coinsurance
Non-Formulary Brand Medications 40% Coinsurance
Mail (90-day supply)
Generic Medications 10% Coinsurance
Formulary Brand Medications 20% Coinsurance
Non-Formulary Brand Medications 40% Coinsurance
Specialty Medications
Generic Medications 20% and $65 Minimum
Formulary Brand Medications 40% and $100 Maximum
Out-of-Pocket Maximums Integrated with Medical