| Co-payment Information | Combined Benefit Fund | 1992 Benefit Plan |
|---|---|---|
| Co-payment Year | March 27 – March 26 | January 1 – December 31 |
| Co-payment Per Physician Visit (Inpatient, Physician office Emergency Room, Routine & Well Baby care) | $5 | $5 |
| Annual Physician Co-Payment Family Maximum | $100 | $100 |
| Hospital Co-Payment | N/A | N/A |
| Co-Payment Per Prescription | $5 | $5 |
| Mail Order Prescription Co-Payment | $0 per 90 day fill | $0 per 90 day fill (first fill per prescription must be for 30 days) |
| Annual Prescription Co-Payment Family Maximum | $50 | $50 |
| Annual Family Out of Pocket Maximum | N/A | N/A |
| Co-payment Information | 1993 Benefit Plan Prefunded Benefit Plan | Alternate Program of Benefits |
|---|---|---|
| Co-payment Year | January 1 – December 31 | January 1 – December 31 |
| Co-payment Per Physician Visit (Inpatient, Physician office, Emergency Room, Routine and Well Baby care) | $20 (PPL Network) $30 (Non-Network) |
$30 (PPL Network) $40 (Non-Network) |
| Outpatient X-Rays, Tests, Allergy Shots, Therapeutic Injections, Therapy visits (ST, PT, OT), and Mental Health/Substance Abuse visits | N/A | $30 (PPL Network) $40 (Non-Network) |
| Annual Outpatient/Physician Co-Payment Family Maximum | $400 (PPL Network) $400 (Non-Network) |
$500 (PPL Network) $500 (Non-Network) |
| Annual Inpatient Hospital Co-Payment Family Maximum | N/A (PPL Network) $600 (Non-Network) |
$750 (PPL Network) $750 (Non-Network) |
| Co-Payment Per Prescription | $15 (PPL Network) $30 (Non-Network) |
$25 (PPL Network) $40 (Non-Network) |
| Mail Order Prescription Co-Payment | $5 per 90 day fill | $10 per 90 day fill |
| Annual Prescription Co-Payment Family Maximum | $600 (PPL Network) $600 (Non-Network) |
$1000 (PPL Network) $1000 (Non-Network) |
| Annual Family Out of Pocket Maximum | $1600 (medical and prescription combined) | $2250 (medical and prescription combined) |
