Page 4 - LegoPowerPoint Presentation

Medical LEGO offers a choice of medical plan options so you can choose

(Aetna) the plan that best meets your needs–and those of your family.

Open Access Aetna PPO BASIC PPO PLUS HDHP with HSA
Select

In Network Only In Network/Out of Network In Network/Out of Network In Network/Out of Network

No Referral Required No Referral Required No Referral Required No Referral Required

Deductible: Deductible: Deductible: Deductible:
In Network In Network Out of Network In Network Out of Network In Network Out of Network
None None $400/800/1,200 None $200/400/600 $2,000/4,000 $2,000/4,000
Co-Insurance 30% Co-Insurance 20%
Max Out of Pocket:
In Network Out of Network
$3,000/6,000 $4,000/8,000

Preventive: $0 Preventive: $0 Preventive: $0 Preventive: $0

Teladoc: $10 Teladoc: $10 Teladoc: $10 Teladoc: $38
Primary Co-Pay: $25 Primary Co-Pay: $25 Primary Co-Pay: $20 Primary Co-Pay: $20

Specialist Co Pay: $30 Specialist Co Pay: $30 Specialist Co Pay: $20 100% covered, after deductible

ER Copay: $175 ER Copay: $175 ER Copay: $150 100% covered, after deductible
In Patient Co Pay: $250 In Patient Co Pay: $250 In Patient Co Pay: $100 100% covered, after deductible

Rx Co Pay: Rx Co Pay: Rx Co Pay: After Deductible: Rx Co Pay:
Retail $10/$25/$40 Retail $10/$25/$40 Retail $10/$20/$35 Retail $10/$25/$40
Mail Order $20/$50/$80 Mail Order $20/$50/$80 Mail Order $20/$40/$70 Mail Order $20/$50/$80
After Out of Pocket Max:
No Co Pay

Health Savings Account (HSA)
• Available if you enroll in a High Deductible Health Plan
• Eligibility Requirements:

• Cannot be claimed as a dependent on someone else’s taxes
• Cannot be covered by another plan that conflicts with an HDHP,
such as Medicare, FSA or HRA.
• Used to pay eligible out-of-pocket healthcare expenses
• LEGO will contribute $1,000 (single) & $2,000 (+1/Family) annually
• Employees can contribute pre-tax dollars through payroll deduction or
make contributions directly to Discovery Benefits ($3,650
Single/$7,300 family, including the employer contribution)

Note: This is a summary of coverage only. Please refer to the summary of benefits coverage for complete information. In-network
services are based on negotiated charges; out-of-network services are based on Reasonable and Customary (R&C) charges. 4

Your Benefit Guide 2020