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 |
| * 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.
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 |
$2,000/$8,000 |
| *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.
