Acom Benefit Guide - Class 1 - Officers, Directors

Medical and Pharmacy Coverage

Acom offers the following plans through Humana. Please reference the Summary Plan Description for more details.

Insurance Carrier:

Humana Medical Insurance

Medical Plan:

$6,500 / 100% On Hand

$6,350 / 100% HSA $6,000 / 100% Copay

In-Network: Office Visit Copay - Primary Care

Virtual Only - $0

Deductible; then 100% Coinsurance

$25

Office Visit Copay - Specialist Care

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

$50

Urgent Care Copay

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

$75

Emergency Room Care

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

Preventative Visit Copay

$0

$0

$0

Diagnostic Testing & Blood Work

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

$0

Imaging

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

Coinsurance

100%

100%

100%

Employee Deductible

$6,500

$6,350

$6,000

Family Deductible

$13,000

$12,700

$12,000

Employee Out-of-Pocket Max

$6,500 (includes deductible)

$6,350 (includes deductible)

$7,900 (includes deductible)

Family Out-of-Pocket Max

$13,000 (includes deductible)

$12,700 (includes deductible)

$15,800 (includes deductible)

Inpatient Hospital

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

Outpatient Hospital or Facility

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

Out-of-Network: Coinsurance

70%

70%

70%

Employee Deductible

$19,050

$19,050

$18,000

Family Deductible

$38,100

$38,100

$36,000

Employee Out-of-Pocket Max

$21,550

$21,550

$23,700

Family Out-of-Pocket Max

$43,100

$43,100

$47,400

Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic

$5

Deductible; then 100% Coinsurance

$15

Tier 2 - Preferred

$5

Deductible; then 100% Coinsurance

$30

Tier 3 - Non-Preferred

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

$50

Tier 4 - Specialty

Deductible; then 100% Coinsurance

Deductible; then 100% Coinsurance

25%

Wellness

Base

Wellness

Base

Wellness

Base

Employee Bi-Weekly Deduction

Employee Only

$55.85 $215.55 $158.75 $297.03

$78.93 $238.62 $181.83 $320.10

$62.10 $229.46 $171.68 $316.66

$85.18 $252.54 $194.76 $339.74

$108.17 $332.08 $267.07 $461.46

$131.24 $355.15 $290.15 $484.53

Employee + Spouse Employee + Child(ren)

Family

6 Acom Integrated Solutions 2022 Enrollment Guide

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