Page 6 - AFL 2022 Manufacturing Guide with Legal Notices

MEDICAL AND PHARMACY COVERAGE

PPO 500 HRA PPO HDHP with HSA
Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Company contribution to HRA 2 2
(Individual/Family) N/A $750 /$1,250 N/A
Annual Deductible
(Individual/Family) $500/$1,500 $1,000/$3,000 $1,500/$3,000 $3,000/$6,000 $3,000/$6,000 $6,000/$12,000
Out-of-Pocket Maximum
(Includes Deductible) $3,000/$9,000 $6,000/$18,000 $4,500/$9,000 $9,000/$18,000 $6,550/$13,100 $13,100/$26,200
Covered at Covered at Covered at
Preventive Care Not covered Not covered Not covered
100% 100% 100%
Amount you pay after deductible
$30 copay
Primary Care Provider 30% 50% 20% 40% after 50%
Office Visit
deductible
$60 copay
Specialist Office Visit 30% 50% 20% 40% after 50%
deductible
X-Ray and Lab 30% 50% 20% 40% 30% 50%
Inpatient Hospital Services 30% 50% 20% 40% 30% 50%
Outpatient Hospital Services 30% 50% 20% 40% 30% 50%
$60 copay
Urgent Care 30% 50% 20% 40% after 50%
deductible
$100 copay, deductible, $100 copay, deductible,
Emergency Room 30%
then 30% then 20%
Pharmacy Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Prescription Drug Deductible $50/$100 $50/$100 Medical deductible
(Individual/Family) applies before copays
Prescription Drug
Out-of-Pocket Maximum $2,350/$4,700 $2,350/$4,700 Medical OOPM Applies
(Individual/Family)
Retail pharmacy (up to a 30-day supply) Amount you pay after deductible
Generic $10 copay $10 copay $10 copay
Brand Preferred $40 copay $40 copay $40 copay
Brand Non-Preferred $55 copay $55 copay $55 copay

Specialty 30% after deductible 30% after deductible $100 copay
Diabetic Medications N/A N/A $20 copay
Mail Order Pharmacy (90-day supply) Amount you pay after deductible
Generic $25 copay $25 copay $25 copay
Brand Preferred $100 copay $100 copay $100 copay
Brand Non-Preferred $137.50 copay $137.50 copay $137.50 copay
Specialty N/A N/A $200 copay

2 Amount is prorated for hires after January 1 of plan year.

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