Page 11 - Acadia 2022 Benefits Guide | DBI

Discover My Acadia Health

Medical Plans At-A-Glance

EPO PLAN
PPO PLAN
HDHP
BENEFIT IN-NETWORK IN-NETWORK IN-NETWORK
Deductible
Individual $500 $1,500 $2,800
Family $1,000 $3,000 $5,600
Out-of-Pocket Maximum
Individual $2,500 $4,000 $7,050
Family $5,000 $8,000 $14,100
Lifetime Maximum Unlimited
Dependent Age Limit To Age 26
Ofice Visits
PhysicianNow $5 copay $10 copay 20% 1
Primary $20 copay $25 copay 20% 1
Specialist $40 copay $50 copay 20% 1
Chiropractic Care (20 visits per year) $40 copay $50 copay 20% 1
Allergy Injections $40 copay $50 copay 20% 1
Preventive Care Preventive care is covered at 100%—deductible and copay waived
Hospital Services
Inpatient $500 copay; 20% 1 20% 1 20% 1
Outpatient $250 copay; 20% 1 20% 1 20% 1
Maternity Service
Prenatal and Postnatal Care $40 copay $50 copay 20% 1
Delivery in Hospital $500 copay; 20% 20% 1 20% 1
Well Baby Care in Hospital Covered Covered Covered
Emergency Treatment
Urgent Care $40 copay $50 copay 20% 1
Emergency Room $250 copay $275 copay 20% 1
Ambulance 20% 1 20% 1 20% 1
Behavioral Health
Inpatient/Outpatient $500 copay; 20% 1 20% 1 20% 1
Ofice Visits $20 copay $25 copay 20% 1
Diagnostic and Therapeutic Services
y Outpatient lab tests, diagnostic 20% 20%
x-ray, radiation therapy at a hospital, 1
chemotherapy 20%
y Physical, occupational, & speech therapy $40 copay $50 copay
Prescription Drugs
(Retail—30-Day Supply)
Generic $10 $10 20% 1, 2
Preferred Brand $40 $40 1 20% 1
Non-Preferred Brand $65 $65 1 20% 1
Prescription Drugs
(Mail Order—90-Day Supply)
Generic $20 $20 20% 1, 2
Preferred Brand $80 $80 1 20% 1
Non-Preferred Brand $130 $130 1 20% 1
Specialty Drugs
Preferred Vendor $120 $130 1 20% 1
Non-Preferred Vendor $240 $260 1 20% 1

Table relects employee portion cost for in-network. See page 6 for more information on the Maintenance Matters Program.
1 After you meet deductible
2 Certain low-cost, generic maintenance medications may be covered at 100%,
deductible waived 2022 Employee Beneits Guide | 11