Page 4 - 2020AONBenefitGuide

Medical and Prescription Benefits

Beneit Highlights PPO High Deductible Health Plan with HSA
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,500 $3,000 $2,500 $5,000
Family $4,500 $9,000 $5,000 $10,000
Out-of-Pocket Maximum
Individual $5,000 $8,000 $5,000 $10,000
Family $10,000 $16,000 $10,000 $20,000
Physician Oice Visits
Preventive Care Covered 100% 40% after deductible Covered 100% 40% coinsurance
Primary Care Visit $25 copay 40% after deductible 10% after deductible 40% after deductible
Specialist Visit $50 copay 40% after deductible 10% after deductible 40% after deductible

Urgent Care $55 copay $55 copay after 10% after deductible 10% after deductible
deductible
Hospital Services
Inpatient 20% after deductible 40% after deductible 10% after deductible 40% after deductible
Outpatient 20% after deductible 40% after deductible 10% after deductible 40% after deductible
Emergency Room 20% after deductible 20% after deductible 10% after deductible 10% after deductible

Employee Bi-Weekly Employer Bi-Weekly
PPO High Deductible Health PPO High Deductible Health
Plan with HSA
Plan with HSA
Employee $60.87 $49.96 $243.47 $199.85
Employee/Spouse $253.51 $199.10 $470.81 $369.77
Employee/Child(ren) $196.00 $153.93 $363.99 $285.87
Family $332.63 $261.01 $616.91 $484.73

Important Information If You Are Covering A Spouse!

Spousal Coverage Elsewhere: a $150 per pay surcharge is added if spouse/domestic partner enrolls on an AON
plan when they are offered coverage through their employer. If enrolling spouse or domestic partner, you must
complete an afidavit certifying they do not have access to medical coverage through their employer.

Note: Physicians may be subject to full premium cost sharing.

4 2020 Benefits Guide