2022 PPO Plan Coverage
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 |
Preventive Drug List | |
Generic Drugs | 10% coinsurance |
Preferred Brand Drugs | 20% coinsurance |
Non-Preferred Brand Drugs | 40 % coinsurance |
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 |