Page 11 - 2022 Smart Solutions - MR

Personal Choice 65 Prime Rx PPO*
Philadelphia Chester, Delaware, and Bucks Montgomery
$7,550 in-network; $11,300 combined in- and out-of-network $0 copay
$35 copay
$250 copay per day for days 1 – 7; no copay for additional days per admission; $1,750 maximum per admission; $0 copay for in-network inpatient hospital stay — acute due to COVID-19 diagnosis
$25 copay per visit (up to 6 visits per year) $20 copay per visit (up to 6 visits per year) $20 copay per visit (up to 6 visits per year)
$60 quarterly allowance1
$0 copay for medical doctor visits focused on non-urgent medical conditions; NEW! $0 copay for behavioral health visits focused on therapy and counseling services
$0 copay for certain diagnostic tests;
$50 or $300 copay depending on the service
Included in plan! See page 14 for details.
Preferred Generic, $0 copay; Generic, $20 copay
Preferred Generic, $0 copay; Generic, $10 copay;
Preferred Brand, $47 copay; Non-Preferred Drug, $100 copay; Specialty Drug, 33% coinsurance
Preferred Generic, $9 copay; Generic, $20 copay;
Preferred Brand, $47 copay; Non-Preferred Drug, $100 copay; Specialty Drug, 33% coinsurance
A maximum of $4,430 in total drug cost
You pay 25% of generic drug costs and 25% of brand-name drug costs until you reach a maximum of $7,050
You pay the greater of $3.95 for generics and $9.85 for brand-name drugs or 5% coinsurance after reaching a maximum of $7,050 catastrophic trigger
NEW! Personal Choice 65 Saver Rx PPO
Philadelphia Chester, Delaware, and Bucks Montgomery
$7,550 in-network; $11,300 combined in- and out-of-network $10 copay
$50 copay
$350 copay per day for days 1 – 5; no copay for additional days per admission; $1,750 maximum per admission; $0 copay for in-network inpatient hospital stay — acute due to COVID-19 diagnosis
$25 copay per visit (up to 6 visits per year) $20 copay per visit (up to 6 visits per year) $20 copay per visit (up to 6 visits per year)
$30 quarterly allowance1
$0 copay for medical doctor visits focused on non-urgent medical conditions; NEW! $0 copay for behavioral health visits focused on therapy and counseling services
$0 copay for certain diagnostic tests;
$55 or $350 copay depending on the service
Included in plan! See page 14 for details.
Preferred Generic, $0 copay; Generic, $20 copay
Preferred Generic, $0 copay; Generic, $10 copay;
Preferred Brand, $47 copay; Non-Preferred Drug, $100 copay; Specialty Drug, 33% coinsurance
Preferred Generic, $9 copay; Generic, $20 copay;
Preferred Brand, $47 copay; Non-Preferred Drug, $100 copay; Specialty Drug, 33% coinsurance
A maximum of $4,430 in total drug cost
You pay 25% of generic drug costs and 25% of brand-name drug costs until you reach a maximum of $7,050
You pay the greater of $3.95 for generics and $9.85 for brand-name drugs or 5% coinsurance after reaching a maximum of $7,050 catastrophic trigger
$0
$0
$0
$0
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