Skip to Content
Contact Us

Medical Copayment Summary

Medical Copayment Summary

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)