MEDICAL & PRESCRIPTION INSURANCE
AMIkids offers medical coverage through Blue Cross Blue Shield for the 2017 plan year. The plan year runs from May 1 st , 2017 – April 30 th , 2018. AMIkids contributes about 75% of the cost for employee coverage on Plan 1 / Base H.S.A. You are responsible for the additional cost associated with buying up to another plan and / or adding dependent(s) on the plan. AMIkids has maintained the employee’s cost for employee coverage on Plan 1 / Base H.S.A. for the past 3 years with no increase and is REDUCING premiums for the 2017 plan year (4 years in a row with no increase!) The chart below provides an overview of the medical plan offered This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review the exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage .
Plan 1 HDHP / Base H.S.A (unchanged from 2016)
Plan 2 Copay / Mid Copay (new for 2017)
Plan 3 Copay / Premium Copay (new for 2017)
IN-NETWORK
Embedded *
Embedded *
Embedded *
* Please see bottom of page 4 (next page) for explanation of Embedded
DEDUCTIBLE (your first dollar cost for covered in-network claims) Deductible (Individual / Family) $2,600 / $5,200
$2,500 / $5,000
$1,500 / $3,000
COINSURANCE (your responsibility on claims costs once you’ve met the deductible) 20% 20% OUT OF POCKET MAXIMUM (once met all in-network covered services are covered by the plan) Maximum Out-of-Pocket (Individual / Family) $5,000 / $10,000 $5,000 / $10,000
20%
$4,500 / $6,850
Maximum Includes
Deductible, Coinsurance, Prescription Costs & Copays
PREVENTIVE CARE Wellness, Immunizations, Mammography, Colonoscopy, etc.
Covered 100%, no cost to you
OFFICE VISITS
Referral Required
No
Teladoc Virtual Visits
$25 copay after deductible
$25 Copay
$25 Copay
Office Visits (Illness/Injury)
20% after deductible
$50 Copay
$35 Copay
Specialist Visits
20% after deductible
$75 Copay
$60 Copay
HOSPITAL SERVICES Inpatient Hospital
20% after deductible
20% after deductible
20% after deductible
Outpatient Surgery
20% after deductible
20% after deductible
20% after deductible
Emergency Room
20% after deductible
$350 Copay
$350 Copay
Urgent Care
20% after deductible
$100 Copay
$100 Copay
DIAGNOSTIC TESTING Lab, X-Ray, Advanced Imaging (MRI, CAT, PET, etc.)
20% after deductible
20% after deductible
20% after deductible
PRESCRIPTIONS
Medical deductible first, then
Retail (30 day supply) Tier 1 / 2 / 3 / 4
$10 / $35 / $60
$10 / $50 / $80 / $100
$10 / $35 / $60
Medicare (Part D) Creditable
No
Yes
Yes
OUT-OF-NETWORK 1 Deductible
1 Charges are subject to balance billing
$7,500 / $15,000
$7,500 / $15,000
$3,000 / $6,000
Coinsurance
50%
50%
50%
Out of Pocket Maximum
$15,000 / $30,000
$15,000 / $30,000
$9,000 / $18,000
WHAT ARE TELADOC VIRTUAL VISITS?
They allow you to see and talk to a doctor from your cell phone, tablet or computer regarding non-emergency medical conditions like the flu, pink eye, rashes and fever. These visits are subject to your deductible but are typically at a lesser cost than an office visit. A way to SAVE TIME AND MONEY!
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