Page 10 - Future Steps
P. 10
Medical Benefits
For a listing of out-of-network beneits, please see the medical plan documents. 2017 changes are noted in bold.
$1,000 Deductible Plan $2,600 Deductible Plan With $3,000 Deductible Plan
HSA
with HSA—NEW
Annual deductible (copayments do not $1,000/person $2,600/person $3,000/person
apply towards the deductible) $2,000/family $5,200/family $6,000/family
Health Savings Account (HSA) Not applicable $500 for employee $500 for employee
Contributed by GESM coverage coverage
$1,000 for employee + $1,000 for employee +
spouse coverage spouse coverage
$1,000 for employee + $1,000 for employee +
child(ren) coverage child(ren) coverage
$1,000 for family coverage $1,000 for family coverage
Coinsurance 80% 100% 80%
Annual Out-of-Pocket Maximum $3,000/person $2,600/person $6,000/person
$6,500/family $5,200/family $12,000/family
Office Visit/Exam 80% after deductible 100% after deductible 80% after deductible
Convenience Care/Retail Health Clinic 80% after deductible 100% after deductible 80% after deductible
Visit
Diagnostic X-Ray or Lab 80% after deductible 100% after deductible 80% after deductible
Adult and Child Preventive Care 100% (no deductible) 100% (no deductible) 100% (no deductible)
Emergency Room Visits 80% after deductible 100% after deductible 80% after deductible
Urgent Care Visits 80% after deductible 100% after deductible 80% after deductible
Inpatient Hospital 80% after deductible 100% after deductible 80% after deductible
Mental Health and Substance Abuse 80% after deductible 100% after deductible 80% after deductible
Chiropractic Services 80% after deductible 100% after deductible 80% after deductible
Retail Prescription Drugs (31-Day Supply)
Tier 1 $12 copay 100% after deductible; no 80% after deductible; no
Tier 2 $45 copay charge for preventive drugs charge for preventive drugs
Tier 3 $90 copay
Specialty Tier You pay 20% to a $200
maximum
Mail order prescription drugs (90-day supply)
2 copays/90-day supply 100% after deductible; no 80% after deductible; no
charge for preventive drugs charge for preventive drugs
Hospital Indemnity Coverage (coverage through Cigna; paid as a reimbursement after filing a claim with
Cigna)
$1,000 Deductible Plan $2,600 Deductible Plan With $3,000 Deductible Plan
HSA
with HSA—NEW
Hospital Admission Not included $1,000 per admission $1,000 per admission
Hospital Chronic Condition Admission $50 per day $50 per day
Hospital Stay $100 per day $100 per day
Hospital Intensive Care Unit Stay $200 per day $200 per day
Hospital Observation Stay $100 per 24-hour period $100 per 24-hour period
Did You Know?
Some preventive medications are covered at 100% under both HSA options. Call HealthPartners
or contact your Human Resources Representative for a complete list of included drugs.
GESM
10
For a listing of out-of-network beneits, please see the medical plan documents. 2017 changes are noted in bold.
$1,000 Deductible Plan $2,600 Deductible Plan With $3,000 Deductible Plan
HSA
with HSA—NEW
Annual deductible (copayments do not $1,000/person $2,600/person $3,000/person
apply towards the deductible) $2,000/family $5,200/family $6,000/family
Health Savings Account (HSA) Not applicable $500 for employee $500 for employee
Contributed by GESM coverage coverage
$1,000 for employee + $1,000 for employee +
spouse coverage spouse coverage
$1,000 for employee + $1,000 for employee +
child(ren) coverage child(ren) coverage
$1,000 for family coverage $1,000 for family coverage
Coinsurance 80% 100% 80%
Annual Out-of-Pocket Maximum $3,000/person $2,600/person $6,000/person
$6,500/family $5,200/family $12,000/family
Office Visit/Exam 80% after deductible 100% after deductible 80% after deductible
Convenience Care/Retail Health Clinic 80% after deductible 100% after deductible 80% after deductible
Visit
Diagnostic X-Ray or Lab 80% after deductible 100% after deductible 80% after deductible
Adult and Child Preventive Care 100% (no deductible) 100% (no deductible) 100% (no deductible)
Emergency Room Visits 80% after deductible 100% after deductible 80% after deductible
Urgent Care Visits 80% after deductible 100% after deductible 80% after deductible
Inpatient Hospital 80% after deductible 100% after deductible 80% after deductible
Mental Health and Substance Abuse 80% after deductible 100% after deductible 80% after deductible
Chiropractic Services 80% after deductible 100% after deductible 80% after deductible
Retail Prescription Drugs (31-Day Supply)
Tier 1 $12 copay 100% after deductible; no 80% after deductible; no
Tier 2 $45 copay charge for preventive drugs charge for preventive drugs
Tier 3 $90 copay
Specialty Tier You pay 20% to a $200
maximum
Mail order prescription drugs (90-day supply)
2 copays/90-day supply 100% after deductible; no 80% after deductible; no
charge for preventive drugs charge for preventive drugs
Hospital Indemnity Coverage (coverage through Cigna; paid as a reimbursement after filing a claim with
Cigna)
$1,000 Deductible Plan $2,600 Deductible Plan With $3,000 Deductible Plan
HSA
with HSA—NEW
Hospital Admission Not included $1,000 per admission $1,000 per admission
Hospital Chronic Condition Admission $50 per day $50 per day
Hospital Stay $100 per day $100 per day
Hospital Intensive Care Unit Stay $200 per day $200 per day
Hospital Observation Stay $100 per 24-hour period $100 per 24-hour period
Did You Know?
Some preventive medications are covered at 100% under both HSA options. Call HealthPartners
or contact your Human Resources Representative for a complete list of included drugs.
GESM
10
