Page 10 - ABM 2021 Benefit Guide MGT HI
P. 10
MEDICAL BENEFITS
ABM provides a choice of plans and premiums Medical and Pharmacy Benefits
to ensure you can make choices that balance A highlight of the plans is shown in the following
cost against other factors that are important table. The coinsurance percentage shown in
to you. Your review should include the plan the charts below represent the amount the team
provisions (e.g., out-of-pocket maximum, member will pay toward the cost.
copays, coinsurance, hospital beneits,
prescription drug beneits) and the amount you HMSA HI Medical
must pay each month. Selecting a plan with Calendar Year Deductible In-Network
a higher out-of-pocket maximum means that Individual $350
your monthly contributions may be less, but Family $1,050
you may have to pay more when you receive Out-of-Pocket Maximum Medical: $3,000
Individual
care. Unless you experience a QLE, the plan Rx: $3,600
you choose now will remain in efect through Family Medical: $9,000
Rx: $4,200
December 31, 2021. Coinsurance 20% team member/80% plan
Physician Oice Visits
HMSA HMO Primary Care $20 copay
$20 copay
Specialist
If you select the HMSA plan, you must use HMSA’s Urgent Care $20 copay
exclusive network of providers to receive coverage. Under Wellness/Preventive No charge
these plans there is no coverage out-of-network unless Lab Services
your event is a qualiied emergency or urgent care that Physician Oice 20%
cannot wait. X-Ray/Radiology Services
Physician Oice 20%
As part of your healthcare beneits, all of our medical plan Hospital Services
choices provide 100% coverage for qualiied wellness/ Inpatient 20%
preventive care services. Outpatient 20%
Emergency Room 20% coinsurance
Mental Health
Inpatient 20%
Outpatient $20 copay
Substance Abuse
Inpatient 20%
Outpatient $20 copay
Prescription Drugs
Retail—Supply Limit 30-day supply
Tier 1 $7 copay
Tier 2 $30 copay
Tier 3 $75 copay
Tier 4 $100 copay
Tier 5 $200 copay
Mail Order—Supply Limit 90-day supply
Tier 1 $11 copay
Tier 2 $65 copay
Tier 3 $200 copay
Tier 4 Not covered
Tier 5 Not covered
10 2021 Benefits Enrollment
ABM provides a choice of plans and premiums Medical and Pharmacy Benefits
to ensure you can make choices that balance A highlight of the plans is shown in the following
cost against other factors that are important table. The coinsurance percentage shown in
to you. Your review should include the plan the charts below represent the amount the team
provisions (e.g., out-of-pocket maximum, member will pay toward the cost.
copays, coinsurance, hospital beneits,
prescription drug beneits) and the amount you HMSA HI Medical
must pay each month. Selecting a plan with Calendar Year Deductible In-Network
a higher out-of-pocket maximum means that Individual $350
your monthly contributions may be less, but Family $1,050
you may have to pay more when you receive Out-of-Pocket Maximum Medical: $3,000
Individual
care. Unless you experience a QLE, the plan Rx: $3,600
you choose now will remain in efect through Family Medical: $9,000
Rx: $4,200
December 31, 2021. Coinsurance 20% team member/80% plan
Physician Oice Visits
HMSA HMO Primary Care $20 copay
$20 copay
Specialist
If you select the HMSA plan, you must use HMSA’s Urgent Care $20 copay
exclusive network of providers to receive coverage. Under Wellness/Preventive No charge
these plans there is no coverage out-of-network unless Lab Services
your event is a qualiied emergency or urgent care that Physician Oice 20%
cannot wait. X-Ray/Radiology Services
Physician Oice 20%
As part of your healthcare beneits, all of our medical plan Hospital Services
choices provide 100% coverage for qualiied wellness/ Inpatient 20%
preventive care services. Outpatient 20%
Emergency Room 20% coinsurance
Mental Health
Inpatient 20%
Outpatient $20 copay
Substance Abuse
Inpatient 20%
Outpatient $20 copay
Prescription Drugs
Retail—Supply Limit 30-day supply
Tier 1 $7 copay
Tier 2 $30 copay
Tier 3 $75 copay
Tier 4 $100 copay
Tier 5 $200 copay
Mail Order—Supply Limit 90-day supply
Tier 1 $11 copay
Tier 2 $65 copay
Tier 3 $200 copay
Tier 4 Not covered
Tier 5 Not covered
10 2021 Benefits Enrollment
