Page 9 - Acadia 2021 Benefits Guide California

Medical Plans At-A-Glance

BUY-UP BASE KAISER
BENEFIT PPO PLAN PPO PLAN HDHP HMO PLAN
IN-NETWORK
IN-NETWORK IN-NETWORK IN-NETWORK
Deductible
Individual $800 $1,600 $2,800 $0
Family $1,600 $3,200 $5,600 $0
Out-of-Pocket Maximum
Individual $4,750 $6,000 $7,000 $1,500
Family $9,500 $12,000 $14,000 $3,000

Lifetime Maximum Unlimited

Dependent Age Limit To Age 26
Ofice Visits
Physician Now $5 Copay $10 Copay $40 Copay Kaiser Telemedicine $0
Primary $20 Copay $25 Copay 20%* $35 Copay
Specialist $40 Copay $50 Copay 20%* $35 Copay

Preventive Care Preventive care is covered at 100% - deductible and copay waived
Hospital Services
Inpatient 20%* 20%* 20%* $250 per Admit
Outpatient 20%* 20%* 20%* $35 per Procedure
Emergency Treatment
Urgent Care $40 Copay $50 Copay 20%* $35 Copay
Emergency Room $250 Copay $250 Copay 20%* $100 per Visit
Ambulance 20%* 20%* 20%* $50 per Trip
Behavioral Health
Inpatient/Outpatient 20%* 20%* 20%* $250 per admit
Ofice Visits $20 Copay $25 Copay 20%* $35 Copay
Prescription Drugs
(Retail - 30 Day Supply)
Brand/Specialty
Only Deductible $150 Ind/$300 Family $150 Ind/$300 Family Med Ded Applies N/A
Generic $10 $10 20%* $15
Preferred Brand $40* $40* 20%* $30
Non-Preferred Brand $65* $65* 20%* $30
Prescription Drugs
(Mail Order - 90 Day Supply)
Generic $20 $20 20%* $30
Preferred Brand $80* $80* 20%* $60
Non-Preferred Brand $130* $130* 20%* $60

Specialty Drugs
Preferred Vendor $120* $120* 20%* 30%* ($150 max)
Non-Preferred Vendor $240* $240* 20%* NA

Table relects employee portion cost for in-network. See page 5 for more information on the Maintenance Matters Program.
* After you meet deductible

2021 Employee Beneits Guide | 9