Page 9 - MB Aerospace Benefit Guide + Notices 2021

Medical coverage through Centivo (continued)

MBA HSA High Plan MBA HSA Low Plan
Plan Provisions Plan Provisions
In-Network Out-of-Network In-Network Out-of-Network
Employer HSA Employer HSA
Contribution Contribution
EE $500 EE $500
EE + 1 $750 EE + 1 $750
Family $1,000 Family $1,000
Coinsurance 20% 40% Coinsurance 30% 50%

Annual Deductible Annual Deductible
Individual $3,000 $6,000 Individual $4,000 $8,000
Family $6,000 $12,000 Family $8,000 $16,000
Out-of-Pocket Out-of-Pocket
Maximum Maximum
(Includes Deductible) (Includes Deductible)
Individual $6,900 $10,000 Individual $6,900 $13,800
Family $13,800 $20,000 Family $13,800 $27,600
Lifetime Maximum Unlimited Lifetime Maximum Unlimited
Primary Physician $30 copay after 40% after Primary Physician $30 copay after 50% after
Office Visit deductible deductible Office Visit deductible deductible
$60 copay after 40% after $60 copay after 50% after
Specialist Office Visit Specialist Office Visit
deductible deductible deductible deductible
Inpatient Hospital 20% after 40% after Inpatient Hospital 30% after 50% after
Services deductible deductible Services deductible deductible
Outpatient Hospital 20% after 40% after Outpatient Hospital 30% after 50% after
Services deductible deductible Services deductible deductible
20% after 40% after 30% after 50% after
Urgent Care Urgent Care
deductible deductible deductible deductible
Emergency Room Care 20% after deductible Emergency Room Care 30% after deductible
Prescription Drugs
Retail (30-day supply) Retail (30-day supply)

΅ Tier 1 $10 Copay after deductible ΅ Tier 1 $10 Copay after deductible
΅ Tier 2 $40 Copay after deductible ΅ Tier 2 $40 Copay after deductible
΅ Tier 3 $80 Copay after deductible ΅ Tier 3 $80 Copay after deductible
΅ Tier 4-Specialty $150 Copay after deductible ΅ Tier 4-Specialty $150 Copay after deductible
Mail Order Mail Order
(90-day supply) 2.5 X Retail Copay (90-day supply) 2.5 X Retail Copay
CVS Only CVS Only

Please refer to page 17 to compare payroll deductions for each plan option.

9