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AT&T Mobility National Bargained Benefit Plan
REVISED Tentative Agreement
Option 1 (Traditional PPO Plan) Option 2 (High-Deductible Plan)
Current 2017 2018 2019 2020 2017 2018 2019 2020
Monthly Contributions
Employee Only 82 89 88 98 110 32 44 57 70
+ Child(ren) 169 153 150 168 188 55 75 97 120
+ Spouse 169 245 241 269 302 88 121 156 193
Family 169 260 256 286 321 93 128 166 205
Tobacco Surcharge
0 50 50
Partner Surcharge 0 0 0 100 100 0 0 100 100
In-Network Medical Coverage
Deductible
Employee Only 500 500 650 700 750 1,300
All Other Tiers 1,000 1,000 1,300 1,400 1,500 2,600
Coinsurance
All Tiers 10% 10% 10%
Out-of-Pocket Maximum
Employee Only 2,000 2,500 3,250 3,500 3,750 6,450
All Other Tiers 4,000 5,000 6,500 7,000 7,500 12,900
Prescription Drug Coverage
Deductible
Employee Only None None Integrated with Medical
All Other Tiers None None Integrated with Medical
Copays (30-day Retail, 90-day Mail Order)
Generic 10, 20 10, 20 9, 18
Preferred Brand 30, 60 30, 60 35, 70 35, 70 35, 70 35, 70
Non-Preferred 60, 120
60, 120 60, 120 70, 140 70, 140
70, 140
Out-of-Pocket Maximum
Employee Only 900 900 1,200 1,200 1,200 Integrated with Medical
All Other Tiers 1,800 1,800 2,400 2,400 2,400 Integrated with Medical
Dental Coverage (Employee Only / + 1 / Family)
Monthly Contributions
3 / 9 / 16 7 / 14 / 23
Plan Design Annual Deductible: 25/person (No Change)
Annual Max Benefit: 1,750/person (No Change)
Lifetime Max Orthodonic Benefit: 2,000/person (No Change)
Vision Coverage (Employee Only / + 1 / Family)
Monthly Contributions
2 / 5 / 7 2 / 5 / 8
Plan Design Annual Frame Allowance: 130/person (No Change)
Annual Contact Allowance: 150/person (No Change)
Tobaco Surcharge: Smokers will self-identify in open enrollment. The surcharge will be waived if the
employee enrolls in a free smoking cessation program.
Spouse/Legal Partner Surcharge: will be waived if employee attests that their partner does not have access to
other employer-based coverage.
Medical Out-of-Pocket Maximum: Amounts paid towards the deductible will now count towards your out-of-
pocket maximum.
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