Page 6 - AAG Benefits Guide OOS (Non-CA) Employees
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5 OUR FAMILY CARING FOR YOURS
HDHP 1500 (HSA) MEDICAL COVERAGE
COVERAGE IN-NETWORK OUT-OF-NETWORK
$1,500 / $3,000 $13,500 / $27,000
Deductible (no more than $2,800 per (no more than $13,500 per
individual in the family) individual in the family)
Maximum Out-of-Pocket
(Single/Family) $4,500 / $9,000 $27,000 / $54,000
Physician Services
PCP Office Visits 20% after deductible 50% after deductible
Specialists Office Visits 20% after deductible 50% after deductible
Lab, X-ray (Basic) 20% after deductible 50% after deductible
Complex, Lab and X-ray 20% after deductible 50% after deductible
Well Baby/Child Exam No copay 50% after deductible
Adult Physicals No copay Not covered
Hospital Services
Room & Board 20% after deductible 50% after deductible
Outpatient Surgery 20% after deductible 50% after deductible
Emergency Care
Copayment (waived if admitted) 20% after deductible 20% after deductible
Urgent Care 20% after deductible 50% after deductible
Ambulance - Emergency only 20% after deductible 20% after deductible
Durable Medical Equipment 20% after deductible 50% after deductible
Prescription Drugs
Tier 1 - Generic Formulary $15 copay after deductible Not covered
Tier 2 - Brand Name Formulary $30 copay after deductible Not covered
Tier 3 - Non Formulary $45 copay after deductible Not covered
Tier 4 - Specialty/Injectable $100 copay after deductible Not covered
Mail Order: Up to 90-day supply 2x copay Tier 1, 2 and 3 Not covered
How does a PPO with an HSA Triple tax advantage with a
account work? Health Savings Account (HSA)
You will have to satisfy your deductible // Contributions are tax-free – save the maximum
before the plan will share in the cost allowed and see your account grow!
for services except on in-network
preventive care services. This plan // Interest and earnings are tax-free - this will
makes you eligible to contribute maximize your savings!
pre-tax dollars to a Health Savings // Withdrawals are free – even in retirement, as long
Account (HSA) (See page 7 for as you use them for eligible health care expenses!
eligibility and plan details.).
