2024 Archdiocese of Atlanta / Lay Employee Quick Guide - Flipbook - Page 29
PREMIER PLAN
Covered person pays:
Meritain Health
In-Network
Overview
Out-of-Network
May use both In-Network and Out-of-Network providers
Use Network providers and receive the In-Network level of benefits
Use Non-Network providers, receive the Out-of-Network level of benefits using Usual and
Customary Charges
Annual Deductible
Single
$400
Family
$1,200
Annual Out-of-Pocket Maximum (Does not include deductible)
Single
$1,750
$2,900
Family
$3,500
$5,800
Unlimited
Lifetime Maximum Benefit
Physician's Office Visits/Telemedicine
$20 co-pay
30% after deductible
Routine Care (age 19 and older)
$20 co-pay
Not covered
Vision Materials (i.e. lenses, frames, contacts, etc.)
Maximum Annual Benefit
$250
$4,000
($2,000 per ear, if purchased individually)
Hearing Aid
Maximum Benefit (Every Four Years)
Hospital Expenses (Facility Charges)
10% after deductible
30% after deductible
Hospital Outpatient (Facility Charges)
10% after deductible
30% after deductible
Emergency Room
10% after deductible
30% after deductible
Outpatient Therapies (ex: physical, speech and occupational)
10% after deductible
30% after deductible
$20 co-pay
20 visits
30% after deductible
20 visits
10% after deductible
30% after deductible
$20 co-pay
30% after deductible
Not Covered
Not Covered
10% after deductible
30% after deductible
Retail Pharmacy
Generic / Brand
$10 / $30
Not covered
Mail Order Delivery
Generic / Brand
$20 / $60
Not covered
Chiropractic Care
Calendar year maximum benefit
Mental Health
Inpatient
Outpatient (Including Telemedicine)
Substance Use Disorder
Long Term Care Services
Skilled Nursing Facility (120 days maximum per year), Hospice Care, Home
Health Care
Prescription Drugs
Monthly Contribution
Employee
$122.00
Employee & Child(ren)
$651.00
Employee & Spouse
$809.00
Employee & Family
$825.00
First day following 60 days of full-time employment
Eligibility Date
1.866.303.2689
www.myMERITAIN.com
Contact Information
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