Hospitalization and Surgical Preferred Provider Organization (PPO Sample Clauses

Hospitalization and Surgical Preferred Provider Organization (PPO. Each full-time employee covered by this Agreement, who elects insurance coverage pursuant to this section, shall contribute toward the monthly premiums as follows: The Board will contribute eighty-five percent (85%) of the premium cost for the hospitalization and surgical plan for each employee and each full-time employee will contribute fifteen percent (15%) of the premium cost. Part-time employees covered by this Agreement may acquire the same insurance protection by; contributing fifty percent (50%) of the monthly premium and the Board contributing fifty percent (50%). Coverage shall include a non-gatekeeper PPO with the following plan factors: CORE PLAN IN NETWORK OUT OF NETWORK Office Visit Co-Pay $20.00 Urgent Care Co-Pay $35.00 ER Co-Pay RX Co-Pay RX Mail Order Percentage Paid Carrier/Employee $75.00 $10 Generic $20 Brand Name Formulary $30 Non-Formulary 3 Months for the Cost of 2 Months 90%/10% 70%/30% Deductibles 100/200 300/600 Out of Pocket Max 1000/2000 2000/4000
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