Page 6 - 2020 Goodwill Benefits Guide

Medical and Prescription Drug Plan Details

Medical and Prescription Drug Plan Network S Providers Out-of-Network
Payroll Deductibles (per pay period) Calendar Year Deductible
Semi- Individual $1,250 $2,500
Monthly Monthly Family $2,500 $5,000
Employee $36 .00 $72 .00 Out-of-Pocket Maximum (includes deductibles, coinsurance, and copays)
Only Individual $5,000 $10,000
Employee + $240 .00 $480 .00 Family $10,000 $20,000
Spouse Physician Oice Visits
Employee + $175 .00 $350 .00 Preventive Care 100% covered 50% after deductible
Primary Care Visit
50% after deductible
$25 copay
Child(ren) Specialist Visit $50 copay 50% after deductible
Family $267 .50 $535 .00 PhysicianNow Telehealth $0 copay 50% after deductible
Hospital Services
This is a high level summary of your beneit Inpatient 20% after deductible 50% after deductible
coverage. Full coverage details are available Outpatient 20% after deductible 50% after deductible
in your summary plan description (SPD). In Emergency Room $300 copay
the event there is a discrepancy between
what is relected in this guide and what is Waived if admitted
communicated in your SPD, the terms of your Prescription Drugs
SPD will prevail. Retail—30-day supply or less
Generic $20 copay 50% after deductible
$50 copay
Know Where to Go Preferred Brand Formulary $100 copay 50% after deductible
50% after deductible
Non-Preferred Brand
for Care Formulary
Knowing where to go for care can Specialty 25% to a maximum of a Not covered
$250 copay
save time and money! As long
as you are not facing a medical Mail Order—90-day supply
emergency, remember you have Generic $40 copay 50% after deductible
a 24/7 Nurseline available to Preferred Brand Formulary $100 copay 50% after deductible
you for free. The Nurseline is Non-Preferred Brand $200 copay 50% after deductible
a great resource to help you Formulary
determine where you need to go
for care and possibly diagnose
symptoms. Nurses are available at
800.818.8581 to assist you.

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