Page 7 - Watermark Retirement Communities 2022 Benefits Guide Logan Square Union Before

Medical and Pharmacy Coverage

CONSUMER DRIVEN PLAN
SELECT PLAN ENHANCED PLAN
(HDHP WITH HSA)

Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Associate Only: $750
Company contribution to HSA Associate + Spouse: $1,000 Not applicable Not applicable Not applicable Not applicable
(Individual/Family) Associate + Child(ren): $1,000
Family: $1,500

Annual Deductible
$2,800/$5,600 $5,000/$10,000 $2,500/$7,500 $5,000/$15,000 $1,500/$3,000 $2,500/ $5,000
(Individual/Family)
Out-of-Pocket Maximum $6,000/$12,000 $10,000/$20,000 $6,000/$12,000 $10,000/$30,000 $4,000/$8,000 $8,000/$16,000
(Includes Deductible)
Preventive Care Covered at 100% 40% Covered at 100% 50% Covered at 100% 40%
Amount you pay after deductible

Primary Care Provider
Office Visit 20% 40% $30 Copay 50% $25 Copay 40%

Specialist Office Visit 20% 40% $60 Copay 50% $50 Copay 40%
X-Ray and Lab 20% 40% $25 Copay 50% $25 Copay 40%

Inpatient Hospital Services 20% 40% $500, then 30% 50% 20% 40%

Outpatient Hospital Services 20% 40% 30% 50% 20% 40%

Urgent Care 20% 40% $50 Copay 50% $50 Copay 40%
$250, then 30% after plan
Emergency Room 20% $200 Copay
deductible
Pharmacy Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Retail Pharmacy (up to a 31-day supply)
$20 Copay after
Generic $20 Copay* $20 Copay $20 Copay $10 Copay $10 Copay
deductible
$40 Copay after
Brand Preferred $40 Copay* $40 Copay $40 Copay $25 Copay $25 Copay
deductible
$70 Copay after
Brand Non-Preferred $70 Copay* $60 Copay $60 Copay $40 Copay $40 Copay
deductible
Mail Order Pharmacy (90-day supply)

$40 Copay after
Generic $40 Copay $20 Copay
deductible*
$80 Copay after
Brand Preferred $80 Copay $50 Copay
deductible* Not Covered Not Covered Not Covered
$140 Copay
Brand Non-Preferred after $120 Copay $80 Copay
deductible*

Note: This is a summary of your coverage only. Please refer to your summary plan description for the full scope of coverage. In-network services are based on
negotiated charges; out-of-network services are based on 110% of the published Medicare rates.

* Associates electing the Consumer Driven Plan will need to satisfy their deductible before the pharmacy copays can begin

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