Page 7 - Ampact 2022 Benefit Guide

Medical Plan Options

There are three medical plan options to choose from for the 2022-2023 plan year. All three
utilize the Open Access network with access to HealthPartners' Cigna National network. A
high-level overview is below.

$2,800-100% $1,500-100% $500-$25
Embedded HSA Plan Non-Embedded HSA Plan PPO Plan
Out of Out of
In-Network In-Network In-Network Out of Network
Plan Provision Network Network
Ampact Contribution to HSA
(Individual/Family) $650/$650 $650/$650 N/A
Annual Deductible
(Individual/Family) $2,800/$5,600 $8,500/$17,000 $1,500/$3,000 $4,500/$9,000 $500/$1,500 $3,000/$9,000
Out-of-Pocket Maximum
(Individual/Family) $3,300/$6,600 $25,000/$50,000 $2,000/$4,000 $13,500/$27,000 $3,500/$7,000 $18,000/None

Preventive Care 100% You pay 50% 100% You pay 50% 100% You pay 50%

Office Visit 100% after You pay 50% 100% after You pay 50% $25 copay You pay 50%
deductible deductible
100% after 100% after 100% after
Urgent Care Visit deductible You pay 50% deductible deductible $25 copay $25 copay

Convenience Care Visit 100% after You pay 50% 100% after You pay 50% $10 copay You pay 50%
deductible deductible
Virtual Care – virtuwell/Dr. 100% after 100% after No cost-
on Demand deductible Not Covered deductible Not Covered Unlimited Not Covered
($59)
($59)
Inpatient Hospital Services 100% after You pay 50% 100% after You pay 50% You pay 25% You pay 50%
deductible deductible after deductible after deductible
Outpatient Hospital Services 100% after You pay 50% 100% after You pay 50% You pay 25% You pay 50%
deductible deductible after deductible after deductible
100% after 100% after 100% after 100% after You pay 25% You pay 25%
Emergency Room Care deductible deductible deductible deductible after deductible after deductible

Prescription Drugs In Network In Network
(31 Day Supply) Select Preventive Rx Drugs Select Preventive Rx Drugs
• Generic $0 Generic $50 Brand $0 Generic $50 Brand $15 copay
$50 copay
• Brand All other formulary drugs are All other formulary drugs are $100 copay 50% coinsurance
covered 100% after the
covered 100% after the
• Non-Formulary deductible – Non-formulary deductible Non-formulary drugs 25% up to $500 at retail
• Specialty drugs have 20% coinsurance have 20% coinsurance after the
after the deductible deductible
Out of Network Out of Network
50% coinsurance at retail 50% coinsurance at retail
Mail Order Deductible/ Deductible/
(93 Day Supply) Coinsurance Not Covered Coinsurance Not Covered 3 copays Not Covered

The deductible & out-of-pocket maximum accumulates August 1 through July 31.

5 7
Effective August 1, 2022-July 31, 2023