HSA Plan - My ACI Benefits

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 (HSA).

Access the HSA Medical Plan Everyday Guide

HSA Plan
Where Available	Nationwide except HI Find BCI providers in your area.
Annual Deductible - Associate - Family	Aggregate $2,000 $4,000⁵
Annual Out-of-Pocket Max - Associate - Family	Embedded $6,000 $12,000
	IN-NETWORK - YOU PAY
Preventive Care	$0¹
Teladoc Health Telemedicine Visit - Medical - Mental Health - Dermatology - Nutrition	$20 per visit after deductible $20 per visit after deductible $20 per visit after deductible $20 per visit after deductible
Office Visit - PCP - Specialist	20%¹ 20%¹
Urgent Care	20%¹
Emergency Room	20%¹
Diagnostic Testing	20%¹
Outpatient X-Ray and Lab	20%¹
Hospitalization - Inpatient Semi-Private Room - Inpatient Physician	20%¹ 20%¹
Outpatient Treatment (Physical, Occupational & Speech Therapy)	20%¹
Mental Health/Substance Abuse - Inpatient - Outpatient	20%¹ 20%¹
Pharmacy Retail	30-day supply
- Annual Deductible Applies - Pharmacy Out-of-Pocket Max	Yes Combined with medical
- Specified Preventive Drugs - Generic - Brand Preferred - Brand Non-Preferred	100% covered^2,3,4 $10 copay 20%¹(min $30, max $90) 30%¹(min $60, max $120)
Pharmacy Retail/Mail Order	90-day supply
- Specified Preventive Drugs - Generic - Brand Preferred - Brand Non-Preferred	100% covered^2,3,4 $30 copay 20%¹(min $90, max $270) 30%¹(min $180, max $360)

1) Coinsurance you pay after you meet the annual deductible unless otherwise noted.
2) Annual deductible waived.
3) As specified in essential drug list.
4) Includes additional preventive drugs based on a formulary.
5) The family deductible must be met before any person receives benefits.