Page 6 - Creative Snacks 2023 Benefit Guide

Medical and Pharmacy Coverage

Copay Plan Option HSA Plan Option
Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network

΅ Employee Only: $25
΅ Employee & Spouse/
Creative Snacks bi-weekly contribution N/A Domestic Partner: $40
to HSA (Individual/Family)
΅ Employee & Child(ren): $40
΅ Employee & Family: $75
Annual Deductible (Individual/Family) $1,500/$3,000 $3,000/$6,000 $2,500/$5,000 $5,000/$10,000

$5,000/$7,000 $10,000/$14,000
Out-of-Pocket Maximum
(Includes Deductible) $3,000/$6,000 $6,000/$12,000 Family Member, Family Member,
$10,000 Family $20,000 Family
Preventive Care Covered at 100% 30%* Covered at 100% 30%*
Primary Care Provider Office Visit $25 copay 50%* 20%* 50%*

Specialist Office Visit $25 copay 50%* 20%* 50%*
Telemedicine $25 copay 50%* 20%* 50%*
X-Ray and Lab 20%* 50%* 20%* 50%*
Inpatient Hospital Services 20%* 50%* 20%* 50%*
Outpatient Hospital Services 20%* 50%* 20%* 50%*
Urgent Care $50 copay $50 copay 20%* 50%*

Emergency Room $300 copay 20%
Pharmacy Provisions
Prescription Drug Deductible
(Individual/Family) None None
Retail Pharmacy (up to a 30-day supply)
Generic $10 copay 50% 20%* 50%*
Brand Preferred $45 copay 50% 20%* 50%*
Brand Non-Preferred $60 copay 50% 20%* 50%*
Specialty 25% ($100 max) 50% 20%* 50%*

6