AP Sponsored Group Health and Dental Plans. The design summaries for the Employer’s group health and dental plans are as follows:
AP Sponsored Group Health and Dental Plans a. The design summaries for the Employer’s group health plans are as follows: Premium Plan Basic Plan In Network Out-of-Network In-Network Out of Network Individual/Family Individual/Family Individual/Family Individual/Family Deductible $500/$1,000 $1,000/$2,000 $900/$1,800 $2,100/$4,200 Coinsurance 85% 60% 75% 60% Out-of-pocket maximum (deductible and Rx add up to OOP) $2,400/$4,800 $4,000/$8.000 $3,400/$6,800 $6,500/$13,000 In-patient Hospital You pay: $200 copay then deductible, coinsurance Plan pays 60% You pay: $200 copay, then deductible, coinsurance Plan pays 60% Office Visit You pay $30 PCP / $45 Specialist Plan pays 60% You pay $30 PCP/ $45 Specialist Plan pays 60% Emergency Room $150 copay $150 copay $150 copay $150 copay Retail Rx Mail order Rx Generic Rx $10 copay $20 copay Brand Rx 20% (minimum $30, maximum $100) 20% (minimum $60, maximum $200) Non-Preferred 30% (minimum $50, maximum $100) 30% (minimum $100, maximum $200) Limited Retail Network: Walgreens, Wal-Mart, Xxxxx Xxxxx are excluded from the retail network. Mandatory Rx Mail-order and generics National preferred formulary adopted No coverage for compound drugs. Vision In Network: Out of Network Vision Exam / Lenses / Frames (Contacts in lieu of Lenses) You pay $20/$20/Plan pays up to $175 Plan pays up to $40 / $40 / $80 / Plans pays up to $45. High Deductible Health Plan w/Health Savings Account HDHP with HAS In Network Out of Network Deductible (Individual/Family) $1,400/$2,800 $2,800/$5,600 Coinsurance, you pay 20% 40% Out-of-Pocket Maximum (Individual/Family) $6,750/$13,500 $13,500/$27,000 Inpatient Hospital 20% 40% Emergency Room 20% 40% Office Visits 20% 40% Preventive Visit no cost when in-network 40% HSA Contribution Limits (no AP contribution) $3,550/$7,100 Catch up $1,000 Prescription Drugs Retail: Generic 20% Formulary 20% Non-Formulary 20% Mail Order: Generic 20% Formulary 20% Non-Formulary 20% 1Subject to IRS regulations
