Page 7 - 2016 ACProducts Non-Union
P. 7
ACProducts
Medical Plan Summary
PPO HDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $650 $1,950 * $1,500 $3,000 *
Family $1,950 $5,850 * $3,000 $6,000 *
Total Out-of-Pocket Maximum
Individual $3,650 $5,850 * $6,050 $6,050 *
Family $10,950 $17,550 * $6,850 $12,100 *
Physician Ofice Visits
Primary Care $30 Copay 50% after deductible 80% after deductible 50% after deductible
Specialist $50 Copay 50% after deductible 80% after deductible 50% after deductible
Wellness/Preventive
100% 100%
Lab Service
80% after deductible 50% after deductible 80% after deductible 50% after deductible
X-Ray/Radiology Services
80% after deductible 50% after deductible 80% after deductible 50% after deductible
Hospital Services
Inpatient 80% after deductible 50% after deductible 80% after deductible 50% after deductible
Outpatient 80% after deductible 50% after deductible 80% after deductible 50% after deductible
Emergency Room 80% after $100 copayment 80% after deductible; then $100 copayment
(copay is waived if admitted) applies (waived if admitted as an inpatient)
Prescription Drugs
PPO HDHP
(In-Network Retail Coverage Only) ** (In-Network Coverage Only) **
Annual Deductible $100/year individual, Same as Medical
$300/year family maximum
Retail—Supply Limit 30 days 30 days
Tier 1 Employee pays 25%; $10 min—$100 max 80% after deductible
Tier 2 Employee pays 35%; $25 min—$100 max 80% after deductible
Tier 3 Employee pays 55%; $50 min—$150 max 80% after deductible
Mail Order—Supply Limit 90 days 90 days
Tier 1 Employee pays 20%; $20 min—$200 max 80% after deductible
Tier 2 Employee pays 30%; $50 min—$200 max 80% after deductible
Tier 3 Employee pays 50%; $100 min—$300 max 80% after deductible
* These out-of-network deductible and total out-of-pocket maximums do not account for any balance billing charges; out-of-pocket maximums
includes: deductible, ofice visit copays and RX copays
** Out-of-network mail order prescription drugs are not covered under the PPO; out-of-network retail and mail order prescription drugs are not
covered under the HDHP
7
Medical Plan Summary
PPO HDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $650 $1,950 * $1,500 $3,000 *
Family $1,950 $5,850 * $3,000 $6,000 *
Total Out-of-Pocket Maximum
Individual $3,650 $5,850 * $6,050 $6,050 *
Family $10,950 $17,550 * $6,850 $12,100 *
Physician Ofice Visits
Primary Care $30 Copay 50% after deductible 80% after deductible 50% after deductible
Specialist $50 Copay 50% after deductible 80% after deductible 50% after deductible
Wellness/Preventive
100% 100%
Lab Service
80% after deductible 50% after deductible 80% after deductible 50% after deductible
X-Ray/Radiology Services
80% after deductible 50% after deductible 80% after deductible 50% after deductible
Hospital Services
Inpatient 80% after deductible 50% after deductible 80% after deductible 50% after deductible
Outpatient 80% after deductible 50% after deductible 80% after deductible 50% after deductible
Emergency Room 80% after $100 copayment 80% after deductible; then $100 copayment
(copay is waived if admitted) applies (waived if admitted as an inpatient)
Prescription Drugs
PPO HDHP
(In-Network Retail Coverage Only) ** (In-Network Coverage Only) **
Annual Deductible $100/year individual, Same as Medical
$300/year family maximum
Retail—Supply Limit 30 days 30 days
Tier 1 Employee pays 25%; $10 min—$100 max 80% after deductible
Tier 2 Employee pays 35%; $25 min—$100 max 80% after deductible
Tier 3 Employee pays 55%; $50 min—$150 max 80% after deductible
Mail Order—Supply Limit 90 days 90 days
Tier 1 Employee pays 20%; $20 min—$200 max 80% after deductible
Tier 2 Employee pays 30%; $50 min—$200 max 80% after deductible
Tier 3 Employee pays 50%; $100 min—$300 max 80% after deductible
* These out-of-network deductible and total out-of-pocket maximums do not account for any balance billing charges; out-of-pocket maximums
includes: deductible, ofice visit copays and RX copays
** Out-of-network mail order prescription drugs are not covered under the PPO; out-of-network retail and mail order prescription drugs are not
covered under the HDHP
7
