Co-payment Information |
---|
Co-payment Year |
Co-payment Per Physician Visit (Inpatient, Physician office Emergency Room, Routine & Well Baby care) |
Annual Physician Co-Payment Family Maximum |
Hospital Co-Payment |
Co-Payment Per Prescription |
Mail Order Prescription Co-Payment |
Annual Prescription Co-Payment Family Maximum |
Annual Family Out of Pocket Maximum |
Combined Benefit Fund | 1992 Benefit Plan |
---|---|
March 27 – March 26 | January 1 – December 31 |
$5 | $5 |
$100 | $100 |
N/A | N/A |
$5 | $5 |
$0 per 90 day fill | $0 per 90 day fill (first fill per prescription must be for 30 days) |
$50 | $50 |
N/A | N/A |
Co-payment Information |
---|
Co-payment Year |
Co-payment Per Physician Visit (Inpatient, Physician office, Emergency Room, Routine and Well Baby care) |
Outpatient X-Rays, Tests, Allergy Shots, Therapeutic Injections, Therapy visits (ST, PT, OT), and Mental Health/Substance Abuse visits |
Annual Outpatient/Physician Co-Payment Family Maximum |
Annual Inpatient Hospital Co-Payment Family Maximum |
Co-Payment Per Prescription |
Mail Order Prescription Co-Payment |
Annual Prescription Co-Payment Family Maximum |
Annual Family Out of Pocket Maximum |
1993 Benefit Plan Prefunded Benefit Plan | Alternate Program of Benefits |
---|---|
January 1 – December 31 | January 1 – December 31 |
$20 (PPL Network) $30 (Non-Network) |
$30 (PPL Network) $40 (Non-Network) |
N/A | $30 (PPL Network) $40 (Non-Network) |
$400 (PPL Network) $400 (Non-Network) |
$500 (PPL Network) $500 (Non-Network) |
N/A (PPL Network) $600 (Non-Network) |
$750 (PPL Network) $750 (Non-Network) |
$15 (PPL Network) $30 (Non-Network) |
$25 (PPL Network) $40 (Non-Network) |
$5 per 90 day fill | $10 per 90 day fill |
$600 (PPL Network) $600 (Non-Network) |
$1000 (PPL Network) $1000 (Non-Network) |
$1600 (medical and prescription combined) | $2250 (medical and prescription combined) |