Page 9 - Acadia 2021 Benefits Guide DBI Wellplace

Medical Plans At-A-Glance

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

Lifetime Maximum Unlimited
Dependent Age Limit To Age 26
Ofice Visits
Physician Now $5 Copay $10 Copay $40 Copay
Primary $20 Copay $25 Copay 20%*
Specialist $40 Copay $50 Copay 20%*
Chiropractic Care (20 visits per year) $40 Copay $50 Copay 20%*
Allergy Injections $40 Copay $50 Copay 20%*
Preventive Care Preventive care is covered at 100% - deductible and copay waived

Hospital Services
Inpatient $500 Copay; 20%* 20%* 20%*
Outpatient $250 Copay; 20%* 20%* 20%*
Maternity Services
Prenatal and Postnatal Care $40 Copay $50 Copay 20%*
Delivery in Hospital $500 Copay; 20% 20%* 20%*
Well Baby Care in Hospital Covered Covered Covered
Emergency Treatment
Urgent Care $40 Copay $50 Copay 20%*
Emergency Room $200 Copay $225 Copay 20%*
Ambulance 20%* 20%* 20%*

Behavioral Health
Inpatient/Outpatient $500 Copay; 20%* 20%* 20%*
Ofice Visits $20 Copay $25 Copay 20%*
Diagnostic and
Therapeutic Services
• Outpatient lab tests, diagnostic 20%* 20%* 20%*
x-ray, radiation therapy at a hospital,
chemotherapy
• Physical, occupational, $40 Copay $50 Copay 20%*
& speech therapy
Prescription Drugs
(Retail - 30 Day Supply)
Generic $10 $10 20%*
Preferred Brand $40 $40 20%*
Non-Preferred Brand $65 $65 20%*
Prescription Drugs
(Retail - 90 Day Supply)
Generic $20 $20 20%*
Preferred Brand $80 $80 20%*
Non-Preferred Brand $130 $130 20%*

Specialty Drugs $120/$240 $130/$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