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Medical Copayment Summary

Medical Copayment Summary

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)