25 / 60
23
Medical
Medical Benefits
PERS Care PPO
In Network
Out of Network
Calendar Year Deductible
$500 indiv / $1,000 family
$500 indiv / $1,000 family
Maximum Calendar Year Co-pay
(excl.
pharmacy)
$2,000 indiv / $4,000 family
N/A
Hospitalization
(incl. Mental Health and Substance Abuse)
Deductible
Inpatient/Outpatient
$250
10%
$250
40%
Emergency Room Deductible
Emergency Room Co-pay
(inpatient or observation as outpatient)
Non Emergency Co-pay
(inpatient or observation as outpatient)
$50
10%
10%
$50
10%
40%
Physician Services
(incl. Mental Health & Substance Abuse)
Office Visit Copay
Inpatient
Outpatient/Urgent Care
$20 / visit
10%
$20
40%
40%
40%
Diagnostic X-Ray / Lab
10%
40%
Prescription Rx: Retail
(up to a 30 day supply only)
Generic / Brand Name / Non-formulary
$5 / $20 / $50
$5 / $20 / $50
Prescription Rx: Retail Maintenance
Medications / Mail Order Pharmacy
Retail: taken for 60 days or more not to
exceed 30 day supply; Mail Order: not to
exceed 90 days supply for maintenance drugs
Generic / Brand Name / Non-formulary
$10 / $40 / $100
$10 / $40 / $100
Maximum co-payment/person per
calendar year
$1,000
$1,000
Durable Medical Equipment
10%
40%
Infertility Testing/Treatment
Not covered
Not covered
Occupational/Physical/Speech
Therapy
No charge (inpatient) /
10% (outpatient)
No charge (inpatient) /
10%-40% (outpatient)
Diabetes Services
Glucose Monitoring
Self-Management Training
Coverage varies
$20
Coverage varies
$20
Acupuncture / Chiropractic
(Limited to combined 20 visits/calendar yr)
$15 / visit
40%