Page 7 - Goodwill 2021 Annual Benefits Enrollment
P. 7
2021 Benefits Enrollment
Medical and Prescription Drug Plan Details
Network S Providers Out-of-Network
Calendar Year Deductible
Individual $1,250 $2,500
Family $2,500 $5,000
Out-of-Pocket Maximum (includes deductibles, coinsurance, and copays)
Individual $5,000 $10,000
Family $10,000 $20,000
Physician Oice Visits
Preventive Care 100% covered 50% after deductible
Primary Care Visit $25 copay 50% after deductible
Specialist Visit $50 copay 50% after deductible
PhysicianNow Telehealth $0 copay 50% after deductible
Hospital Services
Inpatient 20% after deductible 50% after deductible
Outpatient 20% after deductible 50% after deductible
Emergency Room $300 copay waived if admitted
Prescription Drugs
Retail—30-day supply or less
Generic $20 copay 50% after deductible
Preferred Brand Formulary $50 copay 50% after deductible
Non-Preferred Brand Formulary $100 copay 50% after deductible
Specialty 25% to a maximum of a $250 copay Not covered
Mail Order—90-day supply
Generic $40 copay 50% after deductible
Preferred Brand Formulary $100 copay 50% after deductible
Non-Preferred Brand Formulary $200 copay 50% after deductible
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there is a
discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Medical and Prescription Drug Plan Payroll Deductibles
(per pay period) Know Where to Go for Care
Semi-Monthly Monthly Knowing where to go for care can save time and money! As
Employee Only $36.00 $72.00 long as you are not facing a medical emergency, remember
you have a 24/7 Nurseline available to you for free. The
Employee + Spouse $240.00 $480.00 Nurseline is a great resource to help you determine where
Employee + Child(ren) $175.00 $350.00 you need to go for care and possibly diagnose symptoms.
Family $267.50 $535.00 Nurses are available at 800.818.8581 to assist you.
7
Medical and Prescription Drug Plan Details
Network S Providers Out-of-Network
Calendar Year Deductible
Individual $1,250 $2,500
Family $2,500 $5,000
Out-of-Pocket Maximum (includes deductibles, coinsurance, and copays)
Individual $5,000 $10,000
Family $10,000 $20,000
Physician Oice Visits
Preventive Care 100% covered 50% after deductible
Primary Care Visit $25 copay 50% after deductible
Specialist Visit $50 copay 50% after deductible
PhysicianNow Telehealth $0 copay 50% after deductible
Hospital Services
Inpatient 20% after deductible 50% after deductible
Outpatient 20% after deductible 50% after deductible
Emergency Room $300 copay waived if admitted
Prescription Drugs
Retail—30-day supply or less
Generic $20 copay 50% after deductible
Preferred Brand Formulary $50 copay 50% after deductible
Non-Preferred Brand Formulary $100 copay 50% after deductible
Specialty 25% to a maximum of a $250 copay Not covered
Mail Order—90-day supply
Generic $40 copay 50% after deductible
Preferred Brand Formulary $100 copay 50% after deductible
Non-Preferred Brand Formulary $200 copay 50% after deductible
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there is a
discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Medical and Prescription Drug Plan Payroll Deductibles
(per pay period) Know Where to Go for Care
Semi-Monthly Monthly Knowing where to go for care can save time and money! As
Employee Only $36.00 $72.00 long as you are not facing a medical emergency, remember
you have a 24/7 Nurseline available to you for free. The
Employee + Spouse $240.00 $480.00 Nurseline is a great resource to help you determine where
Employee + Child(ren) $175.00 $350.00 you need to go for care and possibly diagnose symptoms.
Family $267.50 $535.00 Nurses are available at 800.818.8581 to assist you.
7
