Page 11 - Acadia 2023 Benefits Guide | Cascade

Your Path to Health

Medical Plans At-A-Glance

BUY-UP PPO PLAN BASE PPO PLAN HDHP KAISER HMO PLAN
BENEFIT
IN-NETWORK IN-NETWORK IN-NETWORK IN-NETWORK
Deductible
Individual $800 $1,600 $3,000 $0
Family $1,600 $3,200 $6,000 $0
Out-of-Pocket
Maximum
Individual $4,750 $6,000 $7,050 $1,000
Family $9,500 $12,000 $14,100 $2,000
Lifetime Maximum Unlimited
Dependent Age Limit To Age 26
Ofice Visits
Teladoc $5 copay $10 copay 20% 1 Kaiser Telemedicine $0
Primary $20 copay $25 copay 20% 1 $15 copay; 10%
Specialist $40 copay $50 copay 20% 1 $30 copay; 10%
Preventive Care Preventive care is covered at 100%—deductible and copay waived

Hospital Services
Inpatient 20% 1 20% 1 20% 1 10%
Outpatient 20% 1 20% 1 20% 1 $30 copay, 10%
Emergency Treatment
Urgent Care $40 copay $50 copay 20% 1 $15 copay; 10%
Emergency Room $300 copay $300 copay 20% 1 $150 copay; 10%
Ambulance 20% 1 20% 1 20% 1 20%
Behavioral Health
Inpatient/Outpatient 20% 1 20% 1 20% 1 10%
Ofice Visits $20 copay $25 copay 20% 1 $15 copay; 10%
Prescription Drugs
(Retail—30-Day
Supply)
Brand/Specialty Only $150 ind/$300 family $150 ind/$300 family Medical deductible N/A
Deductible $10 $10 applies $10
Generic $40 1 $40 1 20% 1, 2 $35
Preferred Brand $65 1 $65 1 20% 1 $70
Non-Preferred Brand 20% 1
Prescription Drugs
(Mail Order—90-Day
Supply)
Generic $20 $20 20% 1, 2 $20
Preferred Brand $80 1 $80 1 20% 1 $70
Non-Preferred Brand $130 1 $130 1 20% 1 $140
Specialty Drugs
Preferred Vendor $120 1 $120 1 20% 1 See retail copays
Non-Preferred Vendor $240 1 $240 1 20% 1

Table relects employee portion cost for in-network. See page 6 for more information on the Maintenance Matters Program.

1 After you meet deductible
2 Certain low-cost, generic maintenance medications may be covered at 100%, deductible waived

2023 Employee Beneits Guide | 11