2021 PPO Savings Plan Overview of 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
Health Savings Accounts Seed Money Individual/Family
Band 1: Less than $45,000 $800/$1,600
Band 2: $45,000.01 to $60,000 $600/$1,200
Band 3: $60,000.01 to $90,000 $400/$800
Band 4: More than $90,000 $200/$400
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) (deductible does not apply to Technical service)
Preventive drugs
Generic Drugs 10% Coinsurance
Preferred Brand Drugs 20% Coinsurance
Non-Preferred Brand Drugs 40% Coinsurance
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