Medical – Atlantic Packaging

Medical Insurance

Atlantic Packaging offers two medical plans administered through our Third-Party Administrator, Health Plans, Inc. The chart below provides a brief outline of what is offered.

Please refer to the summary plan description for complete plan details.

Cost of Coverage

Employee Contributions

	Weekly Employee Contributions
	RBR Plan			Network Plan
	Standard Rate	Wellness Rate*	Standard Rate	Wellness Rate*
Employee	$43.02	$19.79	$43.02	$19.79
Employee & Spouse	$122.52	$84.54	$122.52	$84.54
Employee & Child(ren)	$93.85	$61.95	$93.85	$61.95
Employee & Family	$221.08	$168.02	$221.08	$168.02

	Monthly Employee Contributions
	RBR Plan			Network Plan
	Standard Rate	Wellness Rate*	Standard Rate	Wellness Rate*
Employee	$186.44	$85.76	$186.44	$85.76
Employee & Spouse	$530.91	$366.33	$530.91	$366.33
Employee & Child(ren)	$406.70	$268.43	$406.70	$268.43
Employee & Family	$958.01	$728.09	$958.01	$728.09

*Wellness premiums are based on program participation

Coverage

Medical Plan Benefits	RBR Plan	Network Plan
Annual Deductible			In-Network	Out of Network
Individual	$500	$1,500	$3,000
Family	$1,000	$3,000	$6,000
Coinsurance	20%	20%	40%

Maximum Out-of-Pocket*
Individual	$2,500	$5,000	$10,000
Family	$5,000	$10,000	$20,000

Physician Office Visit
Primary Care	$25 copay	$35 copay	40% after deductible
Specialty Care	$50 copay	$75 copay	40% after deductible
Teladoc	$0 copay	$0 copay	Not Available

Preventive Care
Adult Periodic Exams	100% Covered	100% Covered	40% after deductible
Well-Child Care	100% Covered	100% Covered	40% after deductible

Diagnostic Services
X-ray and Lab Tests	100% Covered	100% Covered	40% after deductible
Complex Radiology	20% after deductible	20% after deductible	40% after deductible
Urgent Care Facility	$50 copay	$100 copay	40% after deductible
Emergency Room Facility Charges	$250 copay for first visit, then 20% after deductible for subsequent visits	$500 copay for first visit, then 20% after deductible for subsequent visits
Inpatient Facility Charges	20% after Deductible	20% after Deductible	40% after deductible
Outpatient Facility and Surgical Charges	20% after deductible	20% after Deductible	40% after deductible

Mental Health
Inpatient	20% after deductible	20% after Deductible	40% after deductible
Outpatient	$25 copay	$35 copay	40% after deductible

Substance Abuse
Inpatient	20% after deductible	20% after deductible	40% after deductible
Outpatient	$25 copay	$35 copay	40% after deductible

Other Services
Chiropractic	$50 Copay (30 visits combined with other outpatient therapies per plan year)	$75 Copay (30 visits combined with other outpatient therapies per plan year)	40% after deductible
Acupuncture	$50 Copay	$75 Copay	40% after deductible