PPO Overview of Coverage - 2020

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 (*See note at end of table)
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
Retail (30-day supply)
Generic Drugs 50% Coinsurance
Formulary Brand Drugs 50% Coinsurance
Non-Formulary Brand Drugs 70% Coinsurance
Mail Order (90-day supply)
Generic Drugs 20% Coinsurance
Formulary Brand Drugs 20% Coinsurance
Non-Formulary Brand Drugs 70% Coinsurance
Specialty
Formulary Brand Drugs 50% Coinsurance and $50 Maximum
Non-Formulary Brand Drugs 70% Coinsurance and $100 Maximum
Out-of-Pocket Maximum $2,000/$8,000

*NEW* Preventive Drug List
*COINSURANCE ONLY*

Preventive Drug List
Generic 10% coinsurance
Preferred Brand 20% coinsurance
Non-Preferred Brand 40% coinsurance

* Total Maximum Out-of-Pocket Maximum (TMOOP) is mandated by the federal government effective with plan years beginning on or after January 1, 2014. TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical expense. With plan years beginning on or after January 1, 2020, TMOOP cannot be more than $7,150 for an individual and $14,300 for plans with two or more persons. Your plan satisfies this requirement.

 

2020 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
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
Formulary Brand Drugs 50% Coinsurance
Non-Formulary Brand Drugs 70% Coinsurance
Mail Order (90-day supply)
Generic Drugs 20% Coinsurance
Formulary Brand Drugs 20% Coinsurance
Non-Formulary Brand Drugs 70% Coinsurance
Specialty
Formulary Brand Drugs 50% Coinsurance and $50 Maximum
Non-Formulary Brand Drugs 70% Coinsurance and $100 Maximum
Out-of-Pocket Maximum $1,000/$6,000

*NEW* Preventive Drug List
*COINSURANCE ONLY*

Preventive Drug List
Generic 10% coinsurance
Preferred Brand 20% coinsurance
Non-Preferred Brand 40% coinsurance

* Total Maximum Out-of-Pocket Maximum (TMOOP) is mandated by the federal government effective with plan years beginning on or after January 1, 2014. TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical expense. With plan years beginning on or after January 1, 2020, TMOOP cannot be more than $7,150 for an individual and $14,300 for plans with two or more persons. Your plan satisfies this requirement.