Page 4 - AONNH19

Medical and Pharmacy Benefits

Medical and Prescription Benefits

Benefit Highlights PPO Health Savings Account
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 Office 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
e-Office Visit $10 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
Prescription Drugs—Retail (per 30-day supply)
Preferred Generic $10 copay 50% $10 copay after in- 50% after in-network
Prescription Drugs network deductible deductible
Preferred Brand Name $50 copay 50% $50 copay after in- 50% after in-network
Prescription Drugs network deductible deductible
Non-Preferred $80 copay 50% $80 copay after in- 50% after in-network
Prescription Drugs network deductible deductible
Oral Chemotherapy $10 copay 50% $10 copay after in- 50% after in-network
Drugs network deductible deductible
Mail Order (90-day supply)
Preferred Generic $25 copay $25 after in-network deductible
Prescription Drugs
Preferred Brand Name $125 copay $125 after in-network deductible
Prescription Drugs
Non-Preferred $200 copay $200 after in-network deductible
Prescription Drugs
Oral Chemotherapy $25 copay $25 after in-network deductible
Drugs
Employee Bi-Weekly Employer Bi-Weekly
PPO Health Savings Account PPO Health Savings Account
Employee $71 .61 $58 .78 $704 .15 $578 .00
Employee/Spouse $298 .25 $234 .24 $1,548 .07 $1,215 .81
Employee/Child(ren) $230 .58 $181 .09 $1,196 .83 $939 .96
Family $390 .99 $307 .07 $2,029 .40 $1,593 .84

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.

4 2019 Benefits Enrollment