PHYSICIAN BENEFITS AT A GLANCE | 2024
Medical - Allied Benefit (TPA) Aetna Signature Administrators PPO Network Coinsurance (Member pays) Calendar Year Deductible - Individual - Family Out-of-Pocket Maximum (Deductible included) - Individual -Family
Copay Plan
HSA 1600
HSA 3000
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
20%
40%
20%
40%
0%
40%
( Hughston | In-network) $500 | $1,000 $1,000 | $2,000
$2,000 $4,000
$1,600 $3,200
$3,200 $9,600
$3,000 $6,000
$10,000 $20,000
$4,000 $8,000
$10,000 $20,000
$4,000 $8,000
$15,000 $30,000
$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
Deductible 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
Deductible
Deductible
Urgent Care
Deductible Deductible Deductible
40% after Deductible 40% after Deductible 40% after Deductible
$60 Copay
40% after Deductible 20% after Deductible 40% after Deductible
Inpatient Services Outpatient Services
20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible
Prescriptions (30 Day Supply)
The Prescription Benefit Coverage is Administered by ProAct
Deductible Tier 1 Tier 2 Tier 3 Tier 4 (Specialty Drugs) Mail Order (90 Day Supply) Tier 1 Tier 2 Tier 3 Medical Rates (Monthly) Employee Employee + Spouse Employee + Child(ren) Family
$200 / $400 $10 Copay
Subject to Medical Deductible $10 Copay after Deductible $30 Copay after Deductible $60 Copay after Deductible $120 Copay after Deductible
Subject to Medical Deductible $10 Copay after Deductible $30 Copay after Deductible $60 Copay after Deductible $120 Copay after Deductible
$30 Copay after Rx Deductible $60 Copay after Rx Deductible $120 Copay after Rx 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
$20 Copay after Deductible $60 Copay after Deductible $120 Copay after Deductible
$966.14 $1,736.89 $1,558.98 $2,513.86
$836.43 $1,515.46 $1,358.73 $2,200.01
$772.91 $1,389.51 $1,247.19 $2,011.09
*$7,000 out-of-pocket maximum for an individual in a family plan. Hughston Urgent Ortho visits, would be subject to the primary care physician fee.
HEALTH SAVINGS ACCOUNT (HSA) | MEDCOM The maximum contribution you can make annually into your HSA is as follows:
• Single: $4,150 • Family: $8,300 • Individuals age 55 and older can make additional catch-up contributions of up to $1,000 per year. Eligibility • You must be enrolled in one of Hughston’s HSA Plans. • You cannot be enrolled in a health plan that is not an HSA-eligible plan, such as a full purpose health care flexible spending account (FSA). • You cannot be enrolled in Medicare. • You cannot be claimed as a dependent on someone else’s tax return. Enrollment in the Health Savings Account is not automatic; you must take action to enroll in this benefit.
TELEMEDICINE | TELADOC Telemedicine Is an affordable plan that gives you and your family 24/7/365 access to U.S. Board Certified Physicians who can consult, diagnose, and, if needed, prescribe medication over the phone or via video technology for many common and acute illnesses. Available to members enrolled in one of Hughston’s medical plans.
Long Term Disability (LTD) – MetLife Monthly Benefit
Dental Plan - MetLife Annual Deductible Individual | Family Preventive Services
Premium Plan
Basic Plan
60% of your monthly earnings
$50 | $150
$50 | $150
Maximum Monthly Benefit $15,000 Benefit Waiting Period 90 Days Maximum Benefit Period The later of SSNRA or the period listed in your Certificate of Coverage
100%
100%
Basic Services Major Services
80% 50% 50%
80% N/A N/A
Orthodontia (Child up to age 26) Annual Benefit Maximum Orthodontia Lifetime Maximum Out-of-Network Reimbursement
Physician Paid
$3,000 $1,500
$1,500
EMPLOYEE ASSISTANCE PROGRAM (EAP) | METLIFE Hughston provides a confidential Employee Assistance Program (EAP) to you and members of your household. Examples of services provided by the EAP include financial counseling, professional help with drug/alcohol dependence and grief counseling. Services provided are completely confidential and available 24 hours a day, 7 days a week. VOLUNTARY BENEFITS**| AFLAC Accident Insurance provides a cash benefit for out-of-pocket expenses associated with an accidental injury. Refer to the plan summaries from Aflac for more details. C ancer Insurance provides financial peace of mind if a diagnosis of cancer ever occurs. Short Term Disability Insurance provides partial income replacement in the event of a covered illness or accident that occurs outside of work. Hospital Confinement Insurance complements your present major medical coverage by providing cash benefits that can be used to help pay out-of-pocket expenses associated with hospital confinement.
N/A
90th UCR
90th UCR Basic Plan
Dental Rates (Monthly) Employee Employee + Spouse Employee + Child(ren) Family
Premium Plan
$41.93 $81.04 $78.58 $123.98
$22.51 $40.08 $39.00 $59.37
Out-of-Network Reimbursement
Vision Plan - MetLife
In-Network
Eye Exam Lenses Single Bifocals Trifocals
$10 Copay
Up to $45
Up to $30 Up to $50 Up to $65
$20 Copay $20 Copay $20 Copay
$130 Allowance after $20 Copay*
Frame
Up to $70
Contacts Disposable Medically Necessary
Up to $105 Up to $210
$130 Allowance $20 Copay
Frequency Exam/Lenses or Contacts/Frames
12/12/24 Months
Physician Paid
Vision Rates (Monthly) Employee Employee + Spouse Employee + Child(ren) Family $ 7.38 $12.07 $11.82 $19.45 *Costco, Walmart and Sam’s Club: $70 allowance after $20 eyewear copay.
Contacts & Information YatesLLC Client Advocates Ph: 404.633.4321 | Fax: 404.633.1312 yatesins.com
Basic Life and AD&D **- MetLife Employee Coverage
Medical | Allied Benefit (TPA) Tel.: 800.288.2078 ACP Tel : 855.442.3477 www.alliedbenefit.com Prescription | ProAct Tel.: 1.877.635.9545 www.Proactrx.com Telemedicine | Teladoc
Employee Assistance Program (EAP) | MetLife Tel.: 1.888.319.7819 metlifeeap.lifeworks.com User Name: metlifeeap Password: eap HSA | Medcom Tel.: 1.800.523.7542 www.medcombenefits.com Voluntary Benefits | Aflac Tel.: 1.800.992.3522 www.aflac.com
1x your Basic Annual Earnings, rounded to the next higher $1,000 - up to $150,000
Spouse Coverage
$5,000
Dependent Coverage 15 days to 6 months: $100 | 6 months to age 26: $2,500 Please be advised that should you reach age 65, your coverage will reduce by 35%. Should you reach age 80, your coverage will reduce by 60%. Physician Paid
Tel.: 800.835.2362 www.teladoc.com Dental, Vision, Life & LTD | MetLife
Voluntary Life and AD&D **– MetLife Employee Coverage Guarantee Issue
Increments of $10,000 up to a maximum of $500,000, not to exceed 5x your annual earnings $150,000 Increments of $5,000 up to $250,000, not to exceed 50% of the employee amount $50,000 Flat amount: $2,500, $5,000, $7,500, or $10,000 Up to $10,000
Dental: 1.800.275.4638 Vision: 1.855.638.3931 Life: 1.800.638.5000 LTD: 1.800.858.6506 www.metlife.com
Spouse Coverage Guarantee Issue Dependent Coverag Guarantee Issue
Physician Paid
**If your spouse is also a benefits-eligible employee at Hughston, then you may not be eligible to elect spousal coverage for Life insurance, Accident Insurance, Cancer Insurance, and Hospital Confinement. In addition, only one employee can elect life coverage for the child. Please refer to the plan document for details.
Please Note: This document is intended as a convenient summary of the major points of benefit plans. This document does not cover all provisions, limitations and exclusions. The official plan documents, policies and certificates of insurance govern in all cases and are available for your inspection at any time.
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