Page 5 - Guide

2017 BENEFITS ENROLLMENT

Medical Insurance

In-Network Out-of-Network
Calendar Year Deductible
Individual $4,000 $16,000
Family $8,000 $32,000
Out-of-Pocket Maximum (Copays, Coinsurance, and Deductibles now
accumulate towards this maximum)
Individual $6,000 $24,000
Family $12,000 $48,000
Coinsurance
In-network 10% 50%
Ofice Visit Copays
50% of the maximum
Primary care $20 allowable charge after
physician deductible, subject to
balance billing
50% of the maximum
Preventive care 100% covered allowable charge after
deductible, subject to
balance billing
Emergency room $250 $250
50% of the maximum
Urgent care $50 allowable charge after
deductible, subject to
balance billing
Pharmacy Copays
Generic $10 **
Preferred brand $35 **
Non-preferred $50 **
brand

* Please reference the evidence of coverage for full beneits coverage
** You pay all costs, then ile a claim for reimbursement
Note: when seeing an out of network provider you will be held liable for charges over
the allowed amount which is called balance billing .

Employee Semi-Monthly Medical Cost
Non-Tobacco User Tobacco User
Employee $54 $104
Employee + spouse $204 $254
Employee + child(ren) $167 $217
Family $330 $380

Note: in the months where there are three (3) payroll deductions ALCO will only
deduct your employee contributions on the irst two (2) paychecks.

ALCO MANAGEMENT 5