PPO Plan: Overview of Coverage - Technical Service

Technical Service Employees

2018 PPO Plan Technical Service Employees
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
Individual $7,150
Family $14,300
Coinsurance
Percentage 90%
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 (31-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 $1,000/$6,000

More details and overview of coverage grid.