Page 9 - American Advisors Group Benefit Guide 2_NonCA

EMPLOYEE BENEFITS 9

HSA MEDICAL COVERAGE

COVERAGE HSA 3500
In-Network Out-of-Network

Deductible $3,500 / $6,500 $7,000 / $13,000
Maximum Out-of-Pocket $6,000 / $11,000 $12,000 / $22,000
(Single/Family)
Physician Services
PCP Office Visits 20% after deductible 40% after deductible
Specialists Office Visits 20% after deductible 40% after deductible
Lab, X-ray (Basic) 20% after deductible 40% after deductible
Complex, Lab and X-ray 20% after deductible 40% after deductible
Well Baby/Child Exam No copay 40% after deductible
Adult Physicals No copay Not covered
Hospital Services
Room and Board 20% after deductible 40% after deductible
Outpatient Surgery 20% after deductible 40% after deductible
Emergency Care
Copayment 20% after deductible 20% after deductible
(waived if admitted)
Urgent Care 20% after deductible 40% after deductible
Ambulance - 20% after deductible 20% after deductible
Emergency only
Durable Medical 20% after deductible 40% after deductible
Equipment
Prescription Drugs
Tier 1 - $15 copay after deductible 50% coinsurance
Generic Formulary
Tier 2 - $30 copay after deductible 50% coinsurance
Brand Name Formulary
Tier 3 - Non Formulary $45 copay after deductible 50% coinsurance
Tier 4 - $100 copay after deductible Not covered
Specialty/Injectable
Mail Order: 2x copay Not covered
Up to 90-day supply Tier 1, 2 and 3

How does a PPO with an HSA work?
You will have to satisfy your deductible before the plan will share in the cost for services except on in-network preventive care services.
This plan makes you eligible to contribute pre-tax dollars to a Health Savings Account (HSA) (See page 10 for eligibility and plan details.).

Triple tax advantage with a Health Savings Account (HSA)
» Contributions are tax-free – save the maximum allowed and see your account grow!
» Interest and earnings are tax-free – this will maximize your savings!
» Withdrawals are free – even in retirement, as long as you use them for eligible healthcare expenses!