2022 PPO Savings Plan Overview of 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 |
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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 |