Page 7 - AAG Benefits Guide OOS (Non-CA) Employees

2021 6
BENEFITS

HDHP 3500 (HSA) MEDICAL COVERAGE

COVERAGE 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 & Board 20% after deductible 40% after deductible
Outpatient Surgery 20% after deductible 40% after deductible

Emergency Care
Copayment (waived if admitted) 20% after deductible 20% after deductible

Urgent Care 20% after deductible 40% after deductible

Ambulance - Emergency only 20% after deductible 20% after deductible
Durable Medical Equipment 20% after deductible 40% after deductible

Prescription Drugs

Tier 1 - Generic Formulary $15 copay after deductible 50% coinsurance
Tier 2 - Brand Name Formulary $30 copay after deductible 50% coinsurance

Tier 3 - Non Formulary $45 copay after deductible 50% coinsurance
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

WHAT ARE YOUR 2021 HSA RATES?

CIGNA MEDICAL PLAN OPTIONS - PER PAY PERIOD COST
EMPLOYEE & EMPLOYEE & EMPLOYEE &
PLAN EMPLOYEE ONLY SPOUSE CHILDREN FAMILY
HDHP 1500 (HSA) $75.00 $325.00 $275.00 $500.00

HDHP 3500 (HSA) $25.00 $235.00 $175.00 $330.00