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Apply Off Pennie
Apply On Pennie
Available in all counties except Lancaster
On and off Pennie
$8,550 / $17,100
$25 copay for independent clinical labs / $50 copay for facility owned labs
$4,000 copay per admission
Preferred generic: $4 Nonpreferred generic: $15 Preferred brand: $45 Nonpreferred brand: $70
Preferred generic: $8 Nonpreferred generic: $30 Preferred brand: $90 Nonpreferred brand: $140
Cost Share amounts listed in the chart are for service performed at in-network providers.
Tests and lab work
Summary of benefits and coverage
Simple PPO brochure
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Understanding health insurance