Page 9 - Acadia 2021 Benefits Guide Tower

Medical Plans At-A-Glance

BUY-UP BASE
BENEFIT PPO PLAN PPO PLAN HDHP EPO
IN-NETWORK
IN-NETWORK
IN-NETWORK IN-NETWORK
Deductible
Individual $800 $1,600 $2,800 $500
Family $1,600 $3,200 $5,600 $1,000
Out-of-Pocket Maximum
Individual $4,750 $6,000 $7,000 $2,500
Family $9,500 $12,000 $14,000 $5,000
Lifetime Maximum Unlimited
Dependent Age Limit To Age 26
Ofice Visits
Physician Now $5 Copay $10 Copay $40 Copay $5 Copay
Primary $20 Copay $25 Copay 20%* $20 Copay
Specialist $40 Copay $50 Copay 20%* $40 Copay
Preventive Care Preventive care is covered at 100% - deductible and copay waived
Hospital Services
Inpatient 20%* 20%* 20%* $500 then 20%*
Outpatient 20%* 20%* 20%* $250 then 20%*
Emergency Treatment
Urgent Treatment $40 Copay $50 Copay 20%* $40 Copay
Emergency Room $250 Copay $250 Copay 20%* $200 Copay
Ambulance 20%* 20%* 20%* 20%*
Behavioral Health
Inpatient/Outpatient 20%* 20%* 20%* $500 then 20%*
Ofice Visits $20 Copay $25 Copay 20%* $20 Copay
Therapy – limited to
20-36 visits per therapy 20%* 20%* 20%* $40 Copay
type per beneit period

Prescription Drugs
(Retail - 30 Day Supply)
Brand/Specialty
Only Deductible $150 Ind/$300 Family $150 Ind/$300 Family Medical Ded Applies N/A
Generic $10 $10 20%* $10
Preferred Brand $40* $40* 20%* $40
Non-Preferred Brand $65* $65* 20%* $65

Prescription Drugs
(Mail Order - 90 Day Supply)
Generic $20 $20 20%* $20
Preferred Brand $80* $80* 20%* $80
Non-Preferred Brand $130* $130* 20%* $130
Specialty Drugs
Preferred Vendor $120* $120* 20%* $120
Non-Preferred Vendor $240* $240* 20%* $240

Table relects employee portion cost for in-network. See page 5 for more information on the Maintenance Matters Program.

* After you meet deductible
2021 Employee Beneits Guide | 9