Page 6 - McKenzie 2022 Benefit Guide SD Hourly

MEDICAL AND PHARMACY COVERAGE

HDHP with HSA

Medical Plan Provisions In-Network Out-of-Network
Company contribution to HSA
$1,000 / $1,600 / $2,100
(Individual/Employee + One/Family)

Annual Deductible
$6,650 / $13,300 $13,300 / $26,600
(Individual/Family)

Out-of-Pocket Maximum $6,650 / $13,300 $14,700 / $26,600
(Includes Deductible)
Preventive Care Covered at 100% Covered at 60% after deductible

Primary Care Provider Office Visit 100% after deductible 40% after deductible

Specialist Office Visit 100% after deductible 40% after deductible

X-Ray and Lab 100% after deductible 40% after deductible

Inpatient Hospital Services 100% after deductible 40% after deductible

Outpatient Hospital Services 100% after deductible 40% after deductible

Urgent Care 100% after deductible 40% after deductible

Emergency Room 100% after deductible

Retail Pharmacy (up to 30-day supply) In-Network Out-of-Network
Generic Drug 100% after deductible Not Covered

Formulary Drug 100% after deductible Not Covered

Non-Formulary Brand 100% after deductible Not Covered
Specialty Drugs 100% after deductible Not Covered

ACA Medications No deductible applies Not Covered

Mail Order Pharmacy (90-day supply)

Generic Drug 100% after deductible Not Covered

Formulary Drug 100% after deductible Not Covered
Non-Formulary Brand 100% after deductible Not Covered

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