POS Plan PPO In-Network Co-Pays & DeductiblesEffective 7/1/24* *Please note that prescription drug copayments effective 7/1/24 apply until 1/1/2025 for those enrolled in the Medicare Part D prescription drug benefit per CMS rules. | |
| Service | Co-Pay |
| RX Retail (1 month)* | Generic - $15 Formulary - $30 Non-Formulary - $60 |
| RX Mail Order (3 months)* | Generic - $30 Formulary - $60 Non-Formulary - $95 |
| Chiropractic Care or Physical Therapy | First 15 Visits - $25 |
| Outpatient Hospital | $35 |
| Inpatient Hospital | $125 |
| Emergency Room | $75 |
| Medical Exam | $25 |
| Vision | Vision Exam - $20 Contact Lenses (Standard) - $25 Contact Lens (Disposable) - $25 |
| **Individual Plan In-Network Out of Pocket Maximum (Medical and RX combined) | $7,350 |
| **Family Plan In-Network Out of Pocket Maximum (Medical and RX combined) | $14,700 |
| ** Added As Required by the Affordable Care Act effective 7/1/15 Sample coverage examples can be found on page 6 on the Summary Benefit Comparison | |