Page 12 - Acadia 2024 Benefits Guide | Erlanger

Your Path to Health

Medical Plans At-A-Glance

BUY-UP PPO PLAN MID PPO PLAN HDHP
BENEFIT
IN-NETWORK IN-NETWORK IN-NETWORK
Deductible
Individual $1,300 $1,500 $3,400
Family $2,600 $3,000 $6,800
Out-of-Pocket Maximum
Individual $5,000 $4,000 $7,050
Family $10,000 $8,000 $14,100
Lifetime Maximum Unlimited
Dependent Age Limit To Age 26
Ofice Visits
Teladoc $5 copay $10 copay 20% 1
Primary $25 copay $30 copay 20% 1
Specialist $45 copay $55 copay 20% 1
Preventive Care Preventive care is covered at 100%—deductible and copay waived
Hospital Services
Inpatient 20% 1 20% 1 20% 1
Outpatient 20% 1 20% 1 20% 1
Emergency Treatment
Urgent Care $45 copay $55 copay 20% 1
Emergency Room 20% 1 20% 1 20% 1
Ambulance 20% 1 20% 1 20% 1
Behavioral Health
Inpatient/Outpatient 20% 1 20% 1 20% 1
Ofice Visits $25 copay $30 copay 20% 1
Therapy—limited to 20-36 visits 20% 1 $50 copay 20% 1
per therapy type per beneit period
Prescription Drugs
(Retail—30-Day Supply)
Brand/Specialty Only Deductible $150 ind/$300 family N/A Medical deductible applies
Generic $10 $10 20% 1, 2
Preferred Brand $40 1 $40 20% 1
Non-Preferred Brand $70 1 $70 20% 1
Prescription Drugs
(Mail Order—90-Day Supply)
Generic $20 $20 20% 1, 2
Preferred Brand $80 1 $80 20% 1
Non-Preferred Brand $140 1 $140 20% 1
Specialty Drugs
Preferred Vendor $120 1 $130 20% 1
Non-Preferred Vendor $240 1 $260 20% 1

Table relects employee portion cost for in-network.
1 After you meet deductible
2 Certain low-cost, generic maintenance medications may be covered at 100%, deductible waived

12 | Erlanger Behavioral Health