Choosing healthcare coverage—medical, prescription drug, dental, and vison—is a personal decision based on your needs and the people you cover. Your Pandora healthcare plans, provided through Triple S, provide the coverage you need, like 100% covered preventive care (and more), to keep you and your family healthy.
Medical
| Description | Copayment / Coinsurance |
|---|---|
| Maximum out of pocket (MOOP) | $6,350 (employee)/$12,700 (family) |
| Hospitalization (preferred, non-preferred) | $50/$100 |
| Ambulatory surgery facility | $50 |
| Emergency room | Sickness: $50 Accident: $0 |
| Urgent care facility | $15 |
| Teleconsulta | $25 |
| Office visits (generalist, specialist, sub-specialist) | $10/$12/$15 |
| Salus clinics (labs, radiology, imaging) | $0 |
| Chiropractic (first visit, manipulation) | $15/$7 (max 15 manipulations) |
| Lab, X-ray, specialized radiology, diagnostic tests | 30% |
| Physical, respiratory therapy | $7/$5 |
| Major medical | 20% coinsurance per person or family |
| Vision (eyeglasses or contact lenses) | Up to $150 per insured per year |
| EAP | Up to 10 visits per year; $15 up to 6 visits |
| Life insurance | $10,000 + AD&D |
Prescription drug
| Description | Retail Pharmacy Copayment / Coinsurance |
|---|---|
| Generic | $10 |
| Preferred brand | $20 (minimum) |
| Non-preferred brand | $50 (minimum) |
| Preferred specialty | 50% (max $200) |
| Non-preferred specialty | 50% (max $250) |
| Over the counter (OTC) | $0 |
| Description | Mail Order Copay |
|---|---|
| 90-day generics | $20 |
| 90-day preferred brand | $40 |
| 90-day non-preferred brand | $100 |
Important: If a brand-name drug is chosen when a generic is available, the member pays the brand copay plus the difference in cost between the brand-name and generic drug.
Dental
| Description | Copayment/Coinsurance |
|---|---|
| Basic, preventive, diagnostic, restorative | 0% |
| Endodontic services and oral surgery | 20% |
| Prosthodontic (up to $1,000/year) | 20% |
| Periodontic (up to $1,000/year) | 50% |
Contacts and resources
Triple S
Healthcare
