Page 9 - Acadia 2021 Benefits Guide Erlanger

Medical Plans At-A-Glance

BENEFIT BUY-UP PPO PLAN MID PPO PLAN HDHP
IN-NETWORK
IN-NETWORK
IN-NETWORK
Deductible
Individual $800 $1,500 $2,800
Family $1,600 $3,000 $5,600
Out-of-Pocket Maximum
Individual $4,750 $4,000 $7,000
Family $9,500 $8,000 $14,000

Lifetime Maximum Unlimited

Dependent Age Limit To Age 26
Ofice Visits
PhysicianNow $5 Copay $10 Copay $40 Copay
Primary $20 Copay $25 Copay 20%*
Specialist $40 Copay $50 Copay 20%*

Preventive Care Preventive care is covered at 100% - deductible and copay waived
Hospital Services
Inpatient 20%* 20%* 20%*
Outpatient 20%* 20%* 20%*
Emergency Treatment
Urgent Care $40 Copay $50 Copay 20%*
Emergency Room $250 Copay $225 Copay 20%*
Ambulance 20%* 20%* 20%*
Behavioral Health
Inpatient/Outpatient 20%* 20%* 20%*
Ofice Visits $20 Copay $25 Copay 20%*

Therapy – limited to 20-36 visits
per therapy type per beneit period 20%* $50 Copay* 20%*
Prescription Drugs
(Retail - 30 Day Supply)
Brand/Specialty Only Deductible $150 Ind/$300 Family N/A Medical Deductible Applies
Generic $10 $10 20%*
Preferred Brand $40* $40* 20%*
Non-Preferred Brand $65* $65* 20%*
Prescription Drugs
(Mail Order - 90 Day Supply)
Generic $20 $20 20%*
Preferred Brand $80* $80 20%*
Non-Preferred Brand $130* $130 20%*
Specialty Drugs
Preferred Vendor $120* $130* 20%*
Non-Preferred Vendor $240* $260* 20%*

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