PPO Plan - My ACI Benefits

With the PPO 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.

PPO Plan
Where Available	Nationwide Find BCI providers in your area.
Annual Deductible - Associate - Family	Embedded $900 $1,800
Annual Out-of-Pocket Max - Associate - Family	Embedded $3,750 $7,500
	IN-NETWORK - YOU PAY
Preventive Care	$0²
Teladoc Telemedicine Visit - Medical - Mental Health	$20 per visit $20 per visit
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	No Combined with medical
- ACA Preventive Drugs on Essential Drug List - Generic - Brand Preferred - Brand Non-Preferred	$0 copay (no deductible) $10 copay 20%² (min $30, max $90) 30%² (min $60, max $120)
Pharmacy Retail/Mail Order	90-day supply
- ACA Preventive Drugs on Essential Drug List - Generic - Brand Preferred - Brand Non-Preferred	$0 copay (no deductible) $30 copay 20%² (min $90, max $270) 30%² (min $180, max $360)

1) Coinsurance you pay after you meet the annual deductible unless otherwise noted.
2) Annual deductible waived.