Page 6 - MGM 2020 Benefits

Gold Plan Silver Plan Bronze Plan
PPO PPO HDHP/HSA
Calendar Year Embedded* Embedded* Non-Embedded**
Deductible
Individual $1,500 $5,000 $2,500 $5,000 $1,350 $5,000
Family $3,000 $10,000 $5,000 $10,000 $2,700 $10,000
Out-of-Pocket Maximum
Individual $5,000 $9,000 $5,000 $9,000 $2,600 $9,000
Family $10,000 $18,000 $10,000 $18,000 $5,200 $18,000
Physician Oice Visits
Primary Care $30 copay 50% after $35 copay 50% after 20% after 50% after
deductible deductible deductible deductible
Specialist $50 copay 50% after $70 copay 50% after 20% after 50% after
deductible deductible deductible deductible
Preventive
100% covered 50% after 100% covered 50% after 100% covered 50% after
deductible deductible deductible
Urgent Care
$75 copay 50% after $100 copay 50% after 20% after 50% after
deductible deductible deductible deductible
Hospital Services
Inpatient 20% after 50% after 30% after 50% after 20% after 50% after
deductible deductible deductible deductible deductible deductible
Outpatient 20% after 50% after 30% after 50% after 20% after 50% after
deductible deductible deductible deductible deductible deductible
Emergency Room $300 copay, 50% after $300 copay, 50% after 20% after 50% after
then 20% after deductible then 30% after deductible deductible deductible
deductible deductible
Chiropractic Care $70 copay 50% after $70 copay 50% after 20% after 50% after
deductible deductible deductible deductible
Limitations 30 visits per calender year 30 visits per calender year 30 visits per calender year
Prescription Drugs
Retail—Supply Limit
30-Day Supply
Tier 1 $20 copay Not covered $20 copay Not covered 20% after Not covered
deductible
Tier 2 $40 copay Not covered $40 copay Not covered 20% after Not covered
deductible
Tier 3 $70 copay Not covered $70 copay Not covered 20% after Not covered
deductible
Mail Order—Supply Limit
90-Day Supply
Tier 1 $50 copay Not covered $50 copay Not covered 20% after Not covered
deductible
Tier 2 $100 copay Not covered $100 copay Not covered 20% after Not covered
deductible
Tier 3 $170 copay Not covered $170 copay Not covered 20% after Not covered
deductible
* Family coverage and embedded deductibles—Embedded deductibles mean your plan has individual deductibles for each family member and
the family deductible. When a family member meets his or her deductible, the plan will begin sharing healthcare costs for family member. The
rest of the family still has to satisfy their individual deductible. However, all individual expenses for each family member count toward the family
deductible. Once the family deductible is met (by more than one family member) the plan will share costs for all family members for the rest of
the plan year.
** Family coverage and non-embedded deductibles—With family coverage, a non-embedded deductible only applies to the family deductible. The
plan will not begin sharing the cost of healthcare for any family member until the family deductible is met. It does not matter if one family
member incurs all of the expenses to meet the deductible or if two or more family member split the expenses. Once the family deductible is met,
all family members will have medical expenses paid according to the plan’s coverage.

6 2019 Benefits Guide