Page 6 - 2021 ASG Benefit Guide

Medical and pharmacy coverage

HDHP / HSA 4000 HDHP / HSA 2000 Choice Plus Plan
Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Company contribution to HSA
(Individual/Family) $850/$1,700 $850/$1,700 N/A
Annual Deductible
(Individual/Family) $4,000/$8,000 $8,000/$16,000 $2,000/$4,000 $4,000/$8,000 $500/$1,000 $1,000/$2,000
$5,000/$10,000 $4,000/$8,000
Embedded Embedded
Out-of-Pocket Maximum Family $10,000/$20,000 Family $8,000/$16,000 $4,000/$8,000 $8,000/$16,000
(Includes Deductible) Coverage Coverage
(Inidividual (Individual
OOPM $8,150) OOPM $6,650)
Covered at Covered at Covered at
Preventive Care 50%* 50%* 50%*
100% 100% 100%
Primary Care Provider 20%* 50%* 20%* 50%* $25 copay 50%*
Office Visit
Specialist Office Visit 20%* 50%* 20%* 50%* $50 copay 50%*
X-Ray and Lab 20%* 50%* 20%* 50%* 20%* 50%*
Inpatient Hospital Services 20%* 50%* 20%* 50%* 20%* 50%*
Outpatient Hospital Services 20%* 50%* 20%* 50%* 20%* 50%*
Urgent Care 20%* 50%* 20%* 50%* $50 copay 50%*
Emergency Room 20%* 20%* $250 copay waived if admitted**
Pharmacy Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Prescription Drug Deductible $4,000/$8,000 $2,000/$4,000 $150/$300
(Individual/Family) Deductible (Combined with Medical) Deductible (Combined with Medical) Rx Deductible (Retail Only)
Retail Pharmacy (up to a 30-day supply)
Generic $10 copay* $10 copay* $10 copay
Brand Preferred $40 copay* $40 copay* $40 copay
Brand Non-Preferred $80 copay* $80 copay* $80 copay
Specialty $200 copay* $200 copay* $200 copay

Retail Pharmacy (up to a 90-day supply)
Generic $30 copay* $30 copay* $30 copay
Brand Preferred $120 copay* $120 copay* $120 copay
Brand Non-Preferred $240 copay* $240 copay* $240 copay
Specialty N/A N/A N/A
Mail Order Pharmacy (90-day supply)
Generic $25 copay* $25 copay* $25
Brand Preferred $100 copay* $100 copay* $100
Brand Non-Preferred $200 copay* $200 copay* $200
Specialty N/A N/A N/A

*Amount you pay after calendar year deductible is met
**First 2 ER visits are $250 copay. $500 copay for 3rd visit and beyond.

6