| Basic PPO | ||
|---|---|---|
| Medical / MHSA | In-Network | Out-of-Network |
| Annual Deductible | ||
| Individual | $300 | |
| Family | $900 | |
| Office Visits, ER, Urgent Care | 70% | 50% |
| Coinsurance | 70% | 50% |
| Annual Out-of-Pocket Max | ||
| Individual | $2,500 | |
| Family | $5,000 | |
| Prescription Drugs | ||
| Retail | ||
| Generic | 70%* | 50% |
| Brand on formulary | 65%* | 50% |
| Off formulary | 60%* | 50% |
| Mail Order | ||
| Generic | 70%* | 50% |
| Brand on formulary | 65%* | 50% |
| Off formulary | 60%* | 50% |
| Monthly Contributions | ||
| Nov 2003 – June 2004 | $0.00 (effective 1/1/2004) | |
| July 2004 – June 2005 | $0.00 | |
| Note: Deductibles do not apply toward Annual Out-of-Pocket Max. | ||
|
* Basic PPO prescription drug benefit has an annual out-of-pocket maximum of $2,000 per individual and $4,000 per family. |
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