Page 6 - 2022 Thrall Benefits Guide

Medical Coverage

PPO Plan Choice Fund HSA Plan
Medical Plan Provisions
In-Network Out-of-Network In-Network Out-of-Network
AnnualDeductible
Individual $1,000 $2,000 $2,800 $5,600
Individual + 1 $2,000 $4,000 $5,600 $11,200
Family $3,000 $6,000 $5,600 $11,200
Out-of-Pocket Maximum (Inc.Ded.)
Individual $4,000 $8,000 $6,900 $10,000
Individual +1 $8,000 $16,000 $13,800 $20,000
Family $9,000 $18,000 $13,800 $20,000
Preventive Care Covered at 100% 40% after Deductible Covered at 100% 40% after Deductible

Lifetime Maximum Unlimited Unlimited
Amount you pay afterdeductible In-Network Out-of-Network In-Network Out-of-Network

Primary Care Provider OfficeVisit 15% after Deductible 40% after Deductible 10% after Deductible 40% after Deductible

Specialist Office Visit 15% after Deductible 40% after Deductible 10% after Deductible 40% after Deductible
X-Ray and Lab 15% after Deductible 40% after Deductible 10% after Deductible 40% after Deductible

Inpatient Hospital Services 15% after Deductible 40% after Deductible 10% after Deductible 40% after Deductible
Outpatient Hospital Services 15% after Deductible 40% after Deductible 10% after Deductible 40% after Deductible

$35 Copay then
Urgent Care 40% after Deductible 10% after Deductible 40% after Deductible
Deductible
Emergency Room $100 Copay per visit, then Deductible 10% after Deductible

*Thrall medical plans have embedded deductibles and out-of-pocket maximums. Under an embedded approach, each person only
needs to meet the individual deductible and out-of-pocket maximum before the plan begins paying its share for that individual.
(And, once two or more family members meet the family limits, the plan begins paying its share for all covered family members).

6