Page 6 - AFL 2022 New Hire Guide with Legal Notices

MEDICAL AND PHARMACY COVERAGE

HDHP with HSA

Medical Plan Provisions In-Network Out-of-Network

Annual Deductible (Individual/Family) $3,000/$6,000 $6,000/$12,000
Out-of-Pocket Maximum (Includes Deductible) $6,550/$13,100 $13,100/$26,200
Preventive Care Covered at 100% Not covered
Amount you pay after deductible
Primary Care Provider Office Visit $30 copay after deductible 50%

Specialist Office Visit $60 copay after deductible 50%
X-Ray and Lab 30% 50%
Inpatient Hospital Services 30% 50%
Outpatient Hospital Services 30% 50%
Urgent Care $60 copay after deductible 50%
Emergency Room 30%

Pharmacy Provisions In-Network Out-of-Network
Prescription Drug Deductible (Individual/Family) Medical deductible applies before copays

Retail pharmacy (up to a 30-day supply)
Generic $10 copay
Brand Preferred $40 copay
Brand Non-Preferred $55 copay
Specialty $100 copay

Diabetic Medication $20 copay
Mail Order Pharmacy (90-day supply)
Generic $25 copay
Brand Preferred $100 copay
Brand Non-Preferred $137.50 copay
Specialty $200 copay

Diabetic Medication $50 copay

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