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PPO Plans at a Glance |
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High Value Plan |
Select Value Plan |
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Features |
Network |
Out-of-Network |
Network |
Out-of-Network |
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Annual deductible |
$400/person |
$800/person |
$600/person |
$1,200/person |
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Annual out-of-pocket maximum[1] |
$4,000/person |
$8,000/person |
$5,500/person |
$11,000/person |
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Coinsurance |
80% |
60% |
80% |
60% |
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Lifetime maximum |
$2,000,000 combined benefit for all ACS-sponsored medical plans |
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Doctor office visits |
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Primary care (includes walk-in clinics)
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$20 copay, then plan pays 100% |
60% after deductible |
$25 copay, then plan pays 100% |
60% after deductible |
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Specialist |
$40 copay, then plan pays 100% |
60% after deductible |
$45 copay, then plan pays 100% |
60% after deductible |
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Allergy injections |
100% |
60% after deductible |
100% |
60% after deductible |
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Preventive care/Well baby care |
$20 copay, then plan pays 100% |
60% after deductible |
$25 copay, then plan pays 100% |
60% after deductible |
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Maximum calendar year benefit[2] |
$500 |
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Chiropractic care |
$40 copay, then plan pays 100% |
60% after deductible |
$45 copay, then plan pays 100% |
60% after deductible |
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Maximum calendar year benefit |
30 visits |
20 visits |
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Therapy, including physical, speech and occupational |
80% after deductible |
60% after deductible |
80% after deductible |
60% after deductible |
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Maximum calendar year benefit |
60 visits for each type of therapy |
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Inpatient hospitalization[3] (including inpatient hospice) |
$350 copay/admission, then plan pays 80% after deductible |
$700 copay/admission, then plan pays 60% after deductible |
$350 copay/admission, then plan pays 80% after deductible |
$700 copay/admission, then plan pays 60% after deductible |
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Maternity Outpatient |
$40 copay for first visit |
60% after deductible |
$45 copay for first visit |
60% after deductible |
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Inpatient |
$350 copay/admission, then plan pays 80% after deductible |
$700 copay/admission, then plan pays 60% after deductible |
$350 copay/admission, then plan pays 80% after deductible |
$700 copay/admission, then plan pays 60% after deductible |
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Other maternity |
80% after deductible |
60% after deductible |
80% after deductible |
60% after deductible |
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Outpatient surgery |
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Doctor office
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80% after deductible |
60% after deductible |
80% after deductible |
60% after deductible |
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Surgical facility |
$250 copay, then plan pays 80% after deductible |
$500 copay, then plan pays 60% after deductible |
$250 copay, then plan pays 80% after deductible |
$500 copay, then plan pays 60% after deductible |
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Diagnostic X-ray and lab except for complex imaging |
100%, no deductible |
60% after deductible |
100%, no deductible |
60% after deductible |
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Complex imaging[3] (CT, MRI, PET) |
80% after deductible |
60% after deductible |
80% after deductible |
60% after deductible |
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Chemotherapy and radiation therapy |
80% after deductible |
60% after deductible |
80% after deductible |
60% after deductible |
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Urgent care facilities |
$40 copay, then plan pays 100% |
60% after deductible |
$45 copay, then plan pays 100% |
60% after deductible |
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Emergency room (and related tests and services) |
$150 copay (waived if admitted), then plan pays 80% after deductible Non-emergency services at an emergency room are not covered |
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Ambulance |
80% after deductible for emergency |
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Home health care[3] |
80% after deductible |
60% after deductible |
80% after deductible |
60% after deductible |
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Mental health and substance abuse Inpatient |
$350 copay/admission, then plan pays 80% after deductible |
$700 copay/admission, then plan pays 60% after deductible |
$350 copay/admission, then plan pays 80% after deductible |
$700 copay/admission, then plan pays 60% after deductible |
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Inpatient maximum (combined)[4] |
30 days/per calendar year
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30 days/per calendar year
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30 days/per calendar year
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30 days/per calendar year
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Outpatient |
80% after deductible |
60% after deductible |
80% after deductible |
60% after deductible
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Outpatient maximum (combined)[4] |
45 visits/per calendar year |
45 visits/per calendar year |
45 visits/per calendar year |
45 visits/per calendar year |
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Hearing Exams Calendar year maximum[4] Hearing Aids Hearing aids lifetime maximum benefit[4] |
Office visit copay One
80% after deductible $800 |
60% after deductible One
60% after deductible $800 |
Office visit copay One
80% after deductible $800 |
60% after deductible One
60% after deductible $800 |
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Other covered outpatient expenses not provided in a doctor’s office[3] |
80% after deductible |
60% after deductible |
80% after deductible |
60% after deductible |
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Prescription Drugs Annual prescription drug deductible |
Applies to all retail prescriptions |
Applies to all retail prescriptions |
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30-day Retail
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You Pay: |
Not covered |
You Pay: |
Not covered |
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-Generic |
10% of discounted cost; minimum $10 copay, maximum $20 copay
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15% of the discounted cost; minimum $10 copay, maximum $20 copay |
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-Formulary brand |
20% of discounted cost; minimum $30 copay, maximum $50 copay
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25% of the discounted cost; minimum $30 copay, maximum $60 copay |
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-Non-formulary brand |
25% of discounted cost; minimum $45 copay, maximum $90 copay |
30% of the discounted cost; minimum $45 copay, maximum $100 copay |
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90-day Retail
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You Pay: |
Not covered |
You Pay: |
Not covered |
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-Generic |
10% of discounted cost; minimum $25 copay, maximum $50 copay
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15% of the discounted cost; minimum $25 copay, maximum $50 copay |
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-Formulary brand |
20% of discounted cost; minimum $90 copay, maximum $150 copay
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25% of the discounted cost; minimum $90 copay, maximum $180 copay |
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- Non-formulary brand |
25% of discounted cost; minimum $135 copay, maximum $270 copay |
30% of the discounted cost; minimum $135 copay, maximum $300 copay |
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Mail Order (up to a 90-day supply) |
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Not covered |
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Not covered |
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-Generic |
$25 copay |
$25 copay |
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-Formulary brand |
$75 copay |
$75 copay |
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-Non-formulary brand |
$112.50 copay |
$112.50 copay |
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-Specialty Drugs |
Mail order copays apply for each 30-day supply |
Not covered |
Mail order copays apply for each 30-day supply |
Not covered |
[1] The out-of-pocket maximum does not include the annual deductible, copays, non-covered expenses, expenses over reasonable and customary/negotiated fees, penalties for failing to precertify when required, chiropractic charges, or your share of the cost for treatment for mental illness and substance abuse.
[2] There is no maximum benefit for well baby care up to age two or colonoscopies. In addition, colonoscopies performed by network providers and at network facilities are covered at 80% with no deductible for any diagnosis.
[3] May require precertification. See your Summary Plan Description for details.
[4] Maximums include both network and non-network services combined.
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Questions about your employee benefits or other Human Resources issues? Contact the Workplace Solutions Center at (888) 471-2271.