Page 12 - ABM 2021 Benefit Guide EDU
P. 12
ACA Compliant Coverage
Basic Essential Essential Plus Essential Premium
Inpatient Hospital Dollars shown are paid directly to the team member
Beneits
1st Day in Hospital N/A $300 $300 $3,000
2nd Day in Hospital N/A $300 $300 $1,000
3rd Day in Hospital N/A $300 $300 $1,000
4th to 60th Day in N/A $100 per day $100 per day $100 per day
Hospital (days 4-60) (days 4-60) (days 4-60)
Inpatient Surgery N/A N/A $500 $1,000
Outpatient Surgery N/A N/A $250 $1,000
Maximum Anesthesia N/A N/A $100 $200
Beneit
Outpatient Beneits Dollars shown are paid directly to the team member
Doctor's Oice Visit— N/A N/A N/A $50 per visit
Diagnostic/Sick Care 2 visits per person
4 per family per year
Health Screening N/A $75 (2 times per N/A N/A
Beneit calendar year per
insured)
Virtual Visits 100% unlimited visits 100% unlimited visits 100% unlimited visits 100% unlimited visits
Radiology Beneits N/A N/A N/A Up to $500
(varies on type of test)
Pathology Beneits Dollars shown are paid directly to the team member
Emergency Room N/A N/A N/A $200 per visit
(illness and accident) 2 visits per person
4 per family per year
(illness and accident)
Ambulance Beneit N/A N/A N/A N/A
Direct Primary Care
Primary Care Visits $10 copay $10 copay $10 copay $10 copay
(unlimited visits) (unlimited visits) (unlimited visits) (unlimited visits)
Urgent Care Visits $25 copay $25 copay $25 copay $25 copay
(unlimited visits) (unlimited visits) (unlimited visits) (unlimited visits)
Annual Physical Includes four labs: Includes four labs: Includes four labs: Includes four labs:
CMP/CBC/TSH/Lipid CMP/CBC/TSH/Lipid CMP/CBC/TSH/Lipid CMP/CBC/TSH/Lipid
Prescription Drugs Maximum cost to team member per script
Tier 1 $10 $10 $10 $10
Tier 2 $20 $20 $20 $20
Tier 3 $40 $40 $40 $40
Tier 4 Discount only Discount only Discount only Discount only
12 2021 Benefits Enrollment
Basic Essential Essential Plus Essential Premium
Inpatient Hospital Dollars shown are paid directly to the team member
Beneits
1st Day in Hospital N/A $300 $300 $3,000
2nd Day in Hospital N/A $300 $300 $1,000
3rd Day in Hospital N/A $300 $300 $1,000
4th to 60th Day in N/A $100 per day $100 per day $100 per day
Hospital (days 4-60) (days 4-60) (days 4-60)
Inpatient Surgery N/A N/A $500 $1,000
Outpatient Surgery N/A N/A $250 $1,000
Maximum Anesthesia N/A N/A $100 $200
Beneit
Outpatient Beneits Dollars shown are paid directly to the team member
Doctor's Oice Visit— N/A N/A N/A $50 per visit
Diagnostic/Sick Care 2 visits per person
4 per family per year
Health Screening N/A $75 (2 times per N/A N/A
Beneit calendar year per
insured)
Virtual Visits 100% unlimited visits 100% unlimited visits 100% unlimited visits 100% unlimited visits
Radiology Beneits N/A N/A N/A Up to $500
(varies on type of test)
Pathology Beneits Dollars shown are paid directly to the team member
Emergency Room N/A N/A N/A $200 per visit
(illness and accident) 2 visits per person
4 per family per year
(illness and accident)
Ambulance Beneit N/A N/A N/A N/A
Direct Primary Care
Primary Care Visits $10 copay $10 copay $10 copay $10 copay
(unlimited visits) (unlimited visits) (unlimited visits) (unlimited visits)
Urgent Care Visits $25 copay $25 copay $25 copay $25 copay
(unlimited visits) (unlimited visits) (unlimited visits) (unlimited visits)
Annual Physical Includes four labs: Includes four labs: Includes four labs: Includes four labs:
CMP/CBC/TSH/Lipid CMP/CBC/TSH/Lipid CMP/CBC/TSH/Lipid CMP/CBC/TSH/Lipid
Prescription Drugs Maximum cost to team member per script
Tier 1 $10 $10 $10 $10
Tier 2 $20 $20 $20 $20
Tier 3 $40 $40 $40 $40
Tier 4 Discount only Discount only Discount only Discount only
12 2021 Benefits Enrollment
