$200,000

$75 per quarter per insured person up to a maximum deductible of $300 per policy year

Network providers:

the plan pays 80% after you pay a $300 • copay per admission; you pay the other 20%

Rubenstein Pharmacy

(on campus at Hall Health)

You pay the higher of:

Generic: 20% or $15 copay•

Brand formulary: 30% or $25 copay• Non-formulary: 40% or $30 copay• Maximum copay/coinsurance of up to $200/prescription

UMC/UWP pharmacies

You pay the higher of:

Generic: 30% or $15copay•

Brand formulary: 40% or $25 copay• Non-formulary: 50% or $30 copay• Maximum copay/coinsurance of up to $200/prescription

Out-of-network pharmacies

You pay:

Generic: 50%

Brand formulary: 50%

Non-formulary: 50%

Maximum copay/coinsurance of up to $200/prescription