Page 12 - Acadia | 2024 Benefits Guide | California

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 $1,300 $2,000 $3,400 $0
Family $2,600 $4,000 $6,800 $0
Out-of-Pocket Maximum
Individual $5,000 $6,000 $7,050 $1,500
Family $10,000 $12,000 $14,100 $3,000
Lifetime Maximum Unlimited
Dependent Age Limit To Age 26
Ofice Visits
Teladoc $5 copay $10 copay 20% 1 Kaiser telemedicine $0
Primary $25 copay $30 copay 20% 1 $35 copay
Specialist $45 copay $55 copay 20% 1 $35 copay
Preventive Care Preventive care is covered at 100%—deductible and copay waived
Hospital Services
Inpatient 20% 1 20% 1 20% 1 $250 per admit
Outpatient 20% 1 20% 1 20% 1 $35 per procedure
Emergency Treatment
Urgent Care $45 copay $55 copay 20% 1 $35 copay
Emergency Room 20% 1 20% 1 20% 1 $100 per visit
Ambulance 20% 1 20% 1 20% 1 $50 per trip
Behavioral Health
Inpatient/Outpatient 20% 1 20% 1 20% 1 $250 per admit
Ofice Visits $25 copay $30 copay 20% 1 $35 copay
Prescription Drugs
(Retail—30-Day Supply)
Medical deductible
Brand/Specialty Only Deductible $150 ind/$300 family $150 ind/$300 family N/A
Generic $10 $10 applies $15
1,2
Preferred Brand $40 1 $40 1 20% 1 $30
Non-Preferred Brand $70 1 $70 1 20% $30
20% 1
Prescription Drugs
(Mail Order—90-Day Supply)
Generic $20 $20 20% 1, 2 $30
Preferred Brand $80 1 $80 1 20%1 $60
Non-Preferred Brand $140 1 $140 1 20% 1 $60

Specialty Drugs
Preferred Vendor $120 1 $120 1 20% 1 30% ($150 max)
Non-Preferred Vendor $240 1 $240 1 20% 1 N/A

Table relects employee portion cost for in-network.
1 After you meet deductible
2 Certain low-cost, generic maintenance medications may be covered at 100%, deductible waived

12 | California