MEDICAL & PRESCRIPTION INSURANCE
AMIkids offers medical coverage through Blue Cross Blue Shield for the 2019 plan year. The plan year runs from May 1st, 2019 – April 30th, 2020. AMIkids contributes over 65% of the cost for team member coverage on the Base H.S.A. Plan making this plan one that complies with the affordability rules of the ACA. You are responsible for the additional cost associated with buying up to another plan and / or adding dependent(s) on the plan. 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 .
Base HDHP H.S.A. Plan
Copay H.R.A. Plan
Copay Premium Plan
IN-NETWORK
PREVENTIVE CARE Wellness, Immunizations, Mammography, Colonoscopy, Annual bloodwork, etc. OFFICE VISITS Referral Required? Teledoc Virtual Visits Office Visits (Illness/Injury) Specialist Visits
Covered 100%, no cost to you.
No Meet deductible, then $25 Copay
No $25 Copay $50 Copay $75 Copay
No $25 Copay $35 Copay $60 Copay
Meet deductible, then 20% Meet deductible, then 20%
HOSPITAL SERVICES Inpatient Hospital Outpatient Surgery Emergency Room Urgent Care Clinic
Meet deductible, then 20% Meet deductible, then 20% Meet deductible, then 20% Meet deductible, then 20%
Meet deductible, then 30% Meet deductible, then 30%
Meet deductible, then 20% Meet deductible, then 20%
$500 Copay $100 Copay
$350 Copay $100 Copay
DIAGNOSTIC TESTING Lab, X-Ray, Advanced Imaging (MRI, CAT, PET, etc.)
Meet deductible, then 20%
Meet deductible, then 30%
Meet deductible, then 20%
PRESCRIPTIONS Retail (30 day supply) Tier 1 / 2 / 3
Meet deductible, then $10 / $35 / $60 Copay
$20 / $50 / $80 Copay
$10 / $35 / $60 Copay
Medicare (Part D) Creditable
NO
YES
YES
DEDUCTIBLE (your cost for covered in-network claims) Deductible (Individual / Family) $3,000 / $6,000
$4,500 / $9,000
$1,500 / $3,000
COINSURANCE (your responsibility on claims costs once you’ve met the deductible) 20% 30% OUT OF POCKET MAXIMUM (once met, all in-network covered services are covered by the plan) Maximum Out-of-Pocket (Individual / Family) $6,000 / $12,000 $6,000 / $12,000
20%
$5,000 / $10,000
Max Out-of-Pocket includes
Deductible , Coinsurance, Prescription Costs, and Copays paid by you during the course of the plan year OUT-OF-NETWORK (charges are subject to balance billing)
Deductible Coinsurance Out of Pocket Maximum
$7,500 / $15,000 50% $15,000 / $30,000
$10,000 / $20,000 50% $15,000 / $30,000
$7,500 / $15,000 50% $15,000 / $30,000
1 Charges are subject to balance billing
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 (or a copay depending upon your plan selection) but are typically at a lesser cost than an office visit. A great way to SAVE TIME AND MONEY! To access Teladoc, visit www.teladoc.com or call 1-800-Teladoc (835-2362)
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