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Hughston Benefits Guide
MEDICAL | ALLIED BENEFIT
Your medical coverage is offered through Allied Benefit for the 2024 plan year. Please review your plan summaries or Summary of Benefits and Coverage (SBC) for coverage information and full plan details. As an Allied member, www.alliedbenefit.com allows you to track your health care benefits and access timely information and tools to help you make better health care decisions. You can view your Personal Health Record, view detailed claims information and reports, find providers and access your ID card.
Remember to tell your providers that your plan utilizes the Aetna Signature Network.
Medical - Allied Benefit (TPA) Aetna Signature Administrators PPO Network Coinsurance (Member pays) Calendar Year Deductible - Individual ( Hughston | In-network) - Family ( Hughston | In-network)
Copay Plan
HSA 1600
In-Network
Out-of-Network
In-Network
Out-of-Network
20%
40%
20%
40%
Embedded $500 | $1,000 $1,000 | $2,000
Embedded $2,000 $4,000
Non-Embedded $1,600 $3,200
Non-Embedded $3,200 $9,600
Out-of-Pocket Maximum (Deductible included) - Individual -Family
$4,000 $8,000
$10,000 $20,000
$4,000 $8,000
$15,000 $30,000
Office Visit -Primary - Specialist - Preventive
$25 Copay $50 Copay 100% Covered
40% after Deductible 40% after Deductible 40% after Deductible
20% after Deductible 20% after Deductible 100% Covered
40% after Deductible 40% after Deductible 40% after Deductible
Emergency Room Services (Copay waived if admitted)
$150 Copay
$150 Copay
20% after Deductible
20% after Deductible
Urgent Care
$60 Copay
40% after Deductible 40% after Deductible 40% after Deductible
40% after Deductible 40% after Deductible 40% after Deductible
20% after Deductible 20% after Deductible 20% after Deductible
Inpatient Services Outpatient Services
20% after Deductible 20% after Deductible
Prescripctions (30 Day Supply) Deductible Tier 1 Tier 2 Tier 3 Tier 4 (Specialty Drugs) Mail Order (90 Day Supply) Tier 1 Tier 2 Tier 3 Medical Rates (Bi-Weekly) ** | *** Employee Employee + Spouse Employee + Child(ren) Family
The Prescription Benefit Coverage is Administered by ProAct
$200 Individual / $400 Family $10 Copay $30 Copay after Rx Deductible $60 Copay after Rx Deductible $120 Copay after Rx Deductible
Subject to Medical Deductible $10 Copay after Deductible $30 Copay after Deductible $60 Copay after Deductible $120 Copay after Deductible
$20 Copay $60 Copay after Rx Deductible $120 Copay after Rx Deductible
$20 Copay after Deductible $60 Copay after Deductible $120 Copay after Deductible
$72.07 $299.13 $268.31 $435.09
$52.17 $216.56 $194.25 $315.00
Hughston Urgent Ortho visits are subject to the primary care physician fee.
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