Page 11 - Acadia 2022 Benefits Guide | Tower

Discover My Acadia Health

Medical Plans At-A-Glance

BUY-UP PPO PLAN BASE PPO PLAN HDHP EPO PLAN
BENEFIT
IN-NETWORK IN-NETWORK IN-NETWORK IN-NETWORK
Deductible
Individual $800 $1,600 $2,800 $500
Family $1,600 $3,200 $5,600 $1,000
Out-of-Pocket Maximum
Individual $4,750 $6,000 $7,050 $2,500
Family $9,500 $12,000 $14,100 $5,000

Lifetime Maximum Unlimited
Dependent Age Limit To Age 26
Ofice Visits
PhysicianNow $5 copay $10 copay 20% 1 $5 copay
Primary $20 copay $25 copay 20% 1 $20 copay
Specialist $40 copay $50 copay 20% 1 $40 copay
Preventive Care Preventive care is covered at 100%—deductible and copay waived
Hospital Services
Inpatient 20% 1 20% 1 20% 1 $500 then 20% 1
Outpatient 20% 1 20% 1 20% 1 $250 then 20% 1
Emergency Treatment
Urgent Care $40 copay $50 copay 20% 1 $40 copay
Emergency Room $300 copay $300 copay 20% 1 $250 copay
Ambulance 20% 1 20% 1 20% 1 20% 1

Behavioral Health
Inpatient/Outpatient 20% 1 20% 1 20% 1 $500 then 20% 1
Ofice Visits $20 copay $25 copay 20% 1 $20 copay
Therapy—limited to 20-36 visits 20% 1 20% 1 20% 1 $40 copay
per therapy type per beneit period
Prescription Drugs
(Retail—30-Day Supply)
Medical deductible
Brand/Specialty Only Deductible $150 ind/$300 family $150 ind/$300 family applies N/A
Generic $10 $10 20% 1, 2 $10
Preferred Brand $40 1 $40 1 20% 1 $40
Non-Preferred Brand $65 1 $65 1 20% 1 $65
Prescription Drugs
(Mail Order—90-Day Supply)
Generic $20 $20 20% 1, 2 $20
Preferred Brand $80 1 $80 1 20% 1 $80
Non-Preferred Brand $130 1 $130 1 20% 1 $130
Specialty Drugs
Preferred Vendor $120 1 $120 1 20% 1 $120
Non-Preferred Vendor $240 1 $240 1 20% 1 $240

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