PPO Plan Overview of Coverage

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
COVID-19 Testing: Aetna is waiving all cost sharing for diagnostic testing related to COVID-19, including serological (anti-body) tests. This includes deductibles, copays, and coinsurance. Aenta will also waive cost sharing on the associated provider, urgent care center, or emergency room visit that resulted in an order for or administration of the test. Under federal law, this waiver will remain in place for so long as the federal emergency remains in effect.
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 $2,000/$8,000
New Preventive Drug List - 2020
* LOWER COINSURANCE
Preventive Drug List
Generic Drugs 10% coinsurance
Preferred Brand Drugs 20% coinsurance
Non-Preferred Brand Drugs 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 $8,150 for an individual and $16,300 for plans with two or more persons. Your plan satisfies this requirement as TMOOP is set at $7,150 for an individual and $14,300 for plans with two or more persons.

2020 PPO Plan Coverage - Technical Service
Deductible
Individual $250
Parent/Child(ren) $375
Family $500
Coinsurance Out-of-Pocket Maximum
Individual $1,250
Parent/Child(ren) $1,875
Family $2,500
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
COVID-19 Testing: Aetna is waiving all cost sharing for diagnostic testing related to COVID-19, including serological (anti-body) tests. This includes deductibles, copays, and coinsurance. Aenta will also waive cost sharing on the associated provider, urgent care center, or emergency room visit that resulted in an order for or administration of the test. Under federal law, this waiver will remain in place for so long as the federal emergency remains in effect.
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
New Preventive Drug List - 2020
*NO DEDUCTIBLE, COINSURANCE ONLY
Preventive Drug List
Generic Drugs 10% coinsurance
Preferred Brand Drugs 20% coinsurance
Non-Preferred Brand Drugs 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 $8,150 for an individual and $16,300 for plans with two or more persons. Your plan satisfies this requirement as TMOOP is set at $7,150 for an individual and $14,300 for plans with two or more persons.