2022 PPO Plan Coverage

2022 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

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