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 Weekly Deduction
Employee Only
$27.93 $107.77
$39.46 $119.31
$31.05 $114.73
$42.59 $126.27
$54.08 $166.04 $133.54 $230.73
$65.62 $177.58 $145.08 $242.27
Employee + Spouse Employee + Child(ren)
$79.38
$90.91
$85.84
$97.38
Family
$148.51
$160.05
$158.33
$169.87
6 Acom Integrated Solutions 2022 Enrollment Guide
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