PPO Plan: Overview of Coverage - Faculty & Staff

Plan Coverage for Faculty and Staff

2018 PPO Plan Faculty & Staff
Deductible
Salary Range < $45,000 $45,000 - $60,000 $60,000 - $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
Coinsurance
Percentage 90%
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
Generic Drugs 20% coinsurance
Formulary Brand Drugs 20% coinsurance
Non-Formulary Brand Drugs 70% coinsurance
Specialty
Formulary Drugs 50% and $50 Maximum
Non-Formulary Brand Drugs 70% and $100 maximum
Out-of-Pocket Maximum $2,000/$8,000

More details and overview of coverage grid.