Page 9 - 2022 Penn Engineering Guide

Your Health Coverage

The following charts illustrate the differences in coverage between the PPO Plan and the
Consumer Driven Health Plan - High Deductible PPO (CDHP)

PPO Plan
Preferred Provider Organization (PPO) Costs for In-Network versus Out-of-Network Providers

In- Network Out- of- Network
Annual Calendar $1,000 individual / $2,000 all $5,000 individual / $10,000 all
Year Deductible other tiers other tiers
$30 per office visit / $50 specialist
visit
Copayment $50 per emergency room visit 30% of most covered expenses
after deductible
$150 non-life-threatening
emergency room visit

After satisfying the deductible and
paying
$4,000 for individual coverage, or
Annual Out- of- $6,000 for family coverage, the Unlimited
pocket maximum
Plan will pay 100% of your
covered expenses for the
remainder of the calendar year.
Your weekly cost See rate information on page 19
for coverage
Life time maximum Unlimited

Prescription Drugs

Card Program through 100% after $10 co-payment for generic drugs; $40 co-payment
for brand formulary drugs; $60 co-payment for brand non-
Synchrony Rx by formulary drugs; no deductible. Specialty Pharmacy; 15% co-pay
CVS/Caremark required

100% after $20 co-payment for a 90-day supply of generic drugs

Mail Order Program through $80 co-payment for a 90-day supply of brand formulary drugs
Synchrony Rx by
CVS/Caremark (pick-up $120 co-payment for a 90-day supply of brand non -formulary
available only at a CVS drugs for all
pharmacy)

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