Page 9 - Allegacy 2017 booklet 8.5x11

Allegacy Benefit Solutions Page 9

Medical Benefits cont’d

Member Responsibility

Benefit Feature Core Plan (In-Network) Buy Up Plan (In-Network)

Mental Health & Substance Abuse:
Outpatient-30 visits/year Inpatient-30 days/ 100% covered after deductible 100% covered after deductible
year

Benefit period maximum for Mental Health & Substance Abuse Services is $8,000,
lifetime maximum is $16,000. Pre-certification is required from
Magellan Behavioral Health-1-800-359-2422.
These illnesses are not subject to any of the above durational limits: Bipolar Disorder, Major Depressive Disorder, Obsessive Compulsive
Disorder, Paranoid and Other Psychotic Disorder, Schizoaffective Disorder, Schizophrenia, Post-traumatic Stress Disorder, Anorexia Ner-
vosa, and Bulimia.

 Preventive care is covered at 100% with no deductible.
 90-day supply of prescriptions available through mail order.
 Deductibles and coinsurance maximums are accumulated based on benefit plan year, January 1 to
December 31.
 Dependent children can be covered until the age of 26, regardless of student status, if unmarried. Benefits
will terminate on 26th birthday.

*Generic drugs from the Enhanced Preventive Drug List prescribed for a preventive reason will be covered at
100% with no deductible.

Employee Monthly Cost Pre-Tax for Plan Year 1/1/2017 to 12/31/2017:
Standard Rates
Core Plan Buy Up Plan
Employee Only $100.44 Employee Only $150.66
Emp. + One $339.58 Emp + One $509.38
Emp + Two or more $521.32 Emp + Two or more $781.98

AllHealth Discounted Rates
Core Plan Buy Up Plan
Employee Only $87.34 Employee Only $131.00
Emp. + One $295.30 Emp + One $442.94
Emp + Two or more $453.32 Emp + Two or more $679.98

Health Savings Account

This plan is compatible with a health savings account to be set up through Allegacy Federal Credit Union.
Allegacy will make a total annual contribution of $1,000 to each employee enrolled as an individual, and
$2,000 to each employee enrolled with dependents. This contribution will be divided and deposited monthly
into your Allegacy H.S.A. account. Employees hired after 1/1/17 will receive prorated contributions.
Additional contributions may be made by you on a pre-tax basis, up to the annual maximum amount al-
lowed by the IRS. These amounts are $3,400 for individual and $6,750 for family. Fulltime Allegacy employees
are also eligible to receive additional contributions into their H.S.A. , up to $1,000 for participating in the
wellness incentive program. Please see page 17 for information on the fulltime wellness program.