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Medical
Medical Benefits
PORAC PPO
In Network
Out of Network
Calendar Year Deductible
$300 indiv / $900 family
$600 indiv / $1,800 family
Maximum Calendar Year Co-pay
(excl. pharmacy)
$3,000 indiv / $6,000 family
$3,000 indiv / $6,000 family
Hospitalization
(incl. Mental Health and Substance Abuse)
Deductible
Inpatient/Outpatient
N/A
10%
N/A
10%
Emergency Room Deductible
Emergency Room Co-pay
(inpatient or observation as outpatient)
Non Emergency Co-pay
(inpatient or observation as outpatient)
N/A
10%
50%
N/A
10%
50%
Physician Services
(incl. Mental Health & Substance Abuse)
Office Visit Copay
Inpatient
Outpatient/Urgent Care
$20 / visit
10%
10%
10%
10%
10%
Diagnostic X-Ray / Lab
10%
10%
Prescription Rx: Retail
(up to a 30 day supply only)
Generic / Brand Name / Non-formulary
$10 / $25 / $45
100% up-front cost; paper
claim may be submitted to
request partial reimb.
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
$20 / $40 / $75
N/A
Max. co-pay/person per calendar yr
N/A
N/A
Durable Medical Equipment
20%
20%
Infertility Testing/Treatment
50%
50%
Occupational/Physical/Speech
Therapy
10% (inpatient) /
$20 (outpatient)
10% (inpatient) /
10% (outpatient)
Diabetes Services
Glucose Monitoring
Self-Management Training
Coverage varies
$20
Coverage varies
$20
Acupuncture / Chiropractic
(Limited to combined 20 visits/calendar yr)
$20/visit
(10% for all other
acupuncture services)
10% acupuncture
$35/visit chiropractic
Note: The PORAC PPO plan is only available to PSMA, PSOA and COA employees.