2021 PPO Plan Coverage

2020 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 
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
Preventive Drugs
Generic Drugs 10% Coinsurance
Preferred Brand Drugs 20% Coinsurance
Non-Preferred Brand Drugs 40% Coinsurance
Retail (30-day supply)
Generic Drugs 50% Coinsurance
Preferred Brand Drugs 50% Coinsurance
Non-Preferred Brand Drugs 70% Coinsurance
Mail order
Generic Drugs 20% Coinsurance
Formulary Brand 20% Coinsurance
Non-Formulary 70% Coinsurance
Specialty
Formulary Drugs 50% and $50 Maximum
Non-Formulary Brand 20% Coinsurance
Non-Formulary 70% and $100 Maximum
New Preventive Drug List - 2020
Preventive Drug List
Generic Drugs 10% coinsurance
Preferred Brand Drugs 20% coinsurance
Non-Preferred Brand Drugs 40 % coinsurance
2021 PPO Plan Coverage - Technical Service
Deductible
Individual $250
Parent/Child(ren) $375
Family $500
Coinsurance Out-of-Pocket Maximum
Individual $1,000
Parent/Child(ren) $1,500
Family $2,000
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
Preferred Brand Drugs 50% Coinsurance
Non-Preferred Brand Drugs 70% Coinsurance
Mail Order (90-day supply)
Generic Drugs 20% Coinsurance
Preferred Brand Drugs 20% Coinsurance
Non-Preferred Brand Drugs 70% Coinsurance
Specialty
Preferred Brand Drugs 50% Coinsurance, $50 Maximum
Non-Preferred Brand Drugs 70% Coinsurance, $100 Maximum
Out-of-Pocket Maximum $1,000/$6,000