Page 12 - Parsons and Parsons Corp ODD EE Guide 1 1 17_FINAL 11.1.16

Benefits For Your Health

MEDICAL INSURANCE

BlueCross BlueShield of HMSA
Alabama Hawaii
Plan Name EPO PPO
Eligible Employee Classes Parsons Corp Parsons Corp
Network Name Alabama Blue
Health Benefits BCBS of AL Network Non-Network

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual / Family $250 / $750 $0 / $0 $100 / $300
Co-Insurance (Plan Pays) 90% 90% inpatient 70%
80% outpatient
Office Visit Copay
- Primary Care Physician $25 $12 70% after deductible
- Specialist Office Visit $35 $12 70% after deductible
Out-of-Pocket Maximum
- Individual / Family $3,000 / $6,000 $2,500 / $7,500 $2,500 / $7,500
$3,600 / $4,200 (RX)
Hospitalization
- Inpatient $300, then plan pays 90% 90% after deductible 70% after deductible
- Outpatient 90% after deductible 80% after deductible 70% after deductible
Lab and X-Ray 90% after deductible 90% after deductible 70% after deductible
80% after deductible

Emergency Services $200, then plan pays 90% 80%
Urgent Care $35 $12 70% after deductible
Preventive Care Covered 100% Covered 100% 70% after deductible
Chiropractic 90% covered $12 Copay 70% after deductible

24 Visits/Year 8 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual / Family $0 / $0 $0 / $0 $0 / $0
Retail Pharmacy
- (Generic/Brand/Non-Formulary) $10 / $40 / $80 $7 / $30 / $30 / $100
In network applicable
ACA Preventive Eligible expenses Eligible expenses Copay plus 20%
covered 100% covered 100%
- Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
- (Generic/Brand/Non-Formulary) $20 / $80 / $160 $11 / $65 / $65 / n/a In network applicable

ACA Preventive Eligible expenses Eligible expenses Copay plus 20%
covered 100% covered 100%
- Supply Limit 90 Days 90 Days 30 Days

12