{"id":3118,"date":"2021-10-23T10:37:06","date_gmt":"2021-10-23T10:37:06","guid":{"rendered":"https:\/\/myaci-benefits.com\/?page_id=3118"},"modified":"2025-04-04T09:25:25","modified_gmt":"2025-04-04T16:25:25","slug":"hsaplan","status":"publish","type":"page","link":"https:\/\/myaci.altimateqod.com\/us\/health\/hsaplan\/","title":{"rendered":"HSA Plan"},"content":{"rendered":"

With the HSA Plan, you can see both in-network and out-of-network providers without a referral, but keep in mind staying in-network for care will almost always be less expensive. To help with your share of costs, this plan gives you the option to participate in a Health Savings Account<\/a><\/b> (HSA).<\/p>\n<\/div><\/div><\/div>

\n

HSA Plan<\/strong>
<\/p>\n<\/div><\/div><\/td><\/tr>

Where Available<\/strong>


<\/p>

<\/p><\/p>\n<\/div><\/div><\/td>

Annual Deductible<\/strong>

- Associate<\/p>

- Family<\/p>

<\/p><\/p>\n<\/div><\/div><\/td>

Aggregate

$2,000<\/p><\/p>\n<\/div><\/div>

$4,0005<\/sup><\/p>\n<\/div><\/div><\/td><\/tr>

Annual Out-of-Pocket Max<\/strong>

- Associate<\/p>

- Family<\/p><\/p>\n<\/div><\/div><\/td>

Embedded

$6,000<\/p>

$12,000<\/p><\/p>\n<\/div><\/div><\/td><\/tr>

<\/p>\n<\/div><\/div><\/td>

IN-NETWORK - YOU PAY<\/strong><\/p>\n<\/div><\/div><\/td><\/tr>

Preventive Care<\/strong>
<\/p>\n<\/div><\/div><\/td>

$01<\/sup><\/p>\n<\/div><\/div><\/td><\/tr>

Teladoc Health Telemedicine Visit<\/strong>

- Medical<\/p>

- Mental Health<\/p>

- Dermatology<\/p>

- Nutrition<\/p>


<\/p>

<\/p><\/p>\n<\/div><\/div><\/td>

$20 per visit after deductible

$20 per visit after deductible
<\/p>

$20 per visit after deductible<\/p>

$20 per visit after deductible<\/p><\/p>\n<\/div><\/div><\/td><\/tr>

Office Visit<\/strong>

- PCP<\/p>

- Specialist<\/p><\/p>\n<\/div><\/div><\/td>

<\/p>\n<\/div><\/div>

20%1<\/sup><\/p>\n<\/div><\/div>

20%1<\/sup><\/p>\n<\/div><\/div><\/td><\/tr>

Urgent Care<\/strong>
<\/p>\n<\/div><\/div><\/td>

20%1<\/sup><\/p>\n<\/div><\/div><\/td><\/tr>

Emergency Room<\/strong>
<\/p>\n<\/div><\/div><\/td>

20%1<\/sup><\/p>\n<\/div><\/div><\/td><\/tr>

Diagnostic Testing<\/strong>
<\/p>\n<\/div><\/div><\/td>

20%1<\/sup><\/p>\n<\/div><\/div>


\n<\/div><\/div><\/td><\/tr>

Outpatient X-Ray and Lab<\/strong>
<\/p>\n<\/div><\/div><\/td>

20%1<\/sup><\/p>\n<\/div><\/div>

\n<\/div><\/div><\/td><\/tr>

Hospitalization<\/strong>

- Inpatient Semi-Private Room<\/p>

- Inpatient Physician<\/p>

<\/p><\/p>\n<\/div><\/div><\/td>

<\/p>\n<\/div><\/div>

20%1<\/sup><\/p>\n<\/div><\/div>

20%1<\/sup><\/p>\n<\/div><\/div><\/td><\/tr>

Outpatient Treatment<\/strong>

(Physical, Occupational & Speech Therapy)<\/p><\/p>\n<\/div><\/div><\/td>

20%1<\/sup><\/p>\n<\/div><\/div>

<\/p>\n<\/div><\/div><\/td><\/tr>

Mental Health\/Substance Abuse<\/strong>

- Inpatient<\/p>

- Outpatient<\/p><\/p>\n<\/div><\/div><\/td>

<\/p>\n<\/div><\/div>

20%1<\/sup><\/p>\n<\/div><\/div>

20%1<\/sup><\/p>\n<\/div><\/div><\/td><\/tr>

Pharmacy Retail
<\/p>\n<\/div><\/div><\/td>

30-day supply
<\/p>\n<\/div><\/div><\/td><\/tr>

- Annual Deductible Applies

- Pharmacy Out-of-Pocket Max<\/p><\/p>\n<\/div><\/div><\/td>

Yes

Combined with medical<\/p>

<\/p><\/p>\n<\/div><\/div><\/td><\/tr>

- Specified Preventive Drugs

- Generic<\/p>

- Brand Preferred<\/p>

- Brand Non-Preferred<\/p><\/p>\n<\/div><\/div><\/td>

100% covered2,3,4<\/sup>

<\/p>

$10 copay<\/p>

20%1<\/sup>(min $30, max $90)<\/p>

30%1<\/sup>(min $60, max $120)<\/p><\/p>\n<\/div><\/div><\/td><\/tr>

Pharmacy Retail\/Mail Order
<\/p>\n<\/div><\/div><\/td>

90-day supply<\/p>\n<\/div><\/div><\/td><\/tr>

- Specified Preventive Drugs
- Generic

- Brand Preferred<\/p>

- Brand Non-Preferred<\/p><\/p>\n<\/div><\/div><\/td>

100% covered2,3,4<\/sup>

<\/p>

$30 copay<\/p>

20%1<\/sup>(min $90, max $270)<\/p>

30%1<\/sup>(min $180, max $360)<\/p><\/p>\n<\/div><\/div><\/td><\/tr><\/tbody><\/table>\n<\/div>\n\n<\/div><\/div><\/div>

1) Coinsurance you pay after you meet the annual deductible unless otherwise noted.<\/span>
\n2) Annual deductible waived.<\/span>
\n3) As specified in essential drug list.<\/span>
\n4) Includes additional preventive drugs based on a formulary.<\/span>
\n5) The family deductible must be met before any person receives benefits.<\/span><\/p>\n<\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":1590,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-3118","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages\/3118","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/comments?post=3118"}],"version-history":[{"count":18,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages\/3118\/revisions"}],"predecessor-version":[{"id":8813,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages\/3118\/revisions\/8813"}],"up":[{"embeddable":true,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages\/1590"}],"wp:attachment":[{"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/media?parent=3118"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}