Page 6 - Goodwill of SWPA 2022 Benefits Guide

Medical and pharmacy coverage

Community Blue Flex PPO QHDHP Community Blue Flex PPO with HRA

Medical Plan Provisions Enhanced Value Standard Value Enhanced Value Standard Value

EEs pay the first $500 (Individual)/
Company contribution to HRA None $1,000 (Family) and the HRA subsidizes the
(Employee/Employee +1 or Family)
remaining $2000/$4000, respectively
Deductible per Benefit Period
(Individual/Family) $1,400/$2,800 $2,800/$5,600 $2,500/$5,000 $5,000/$10,000
Coinsurance 80%* 70%* 80%* 70%*
Out-of-Pocket Maximum $5,150/$10,300 $3,800/$7,000 $4,100/$8,200 $1,600/$3,200
(Excludes Deductible)

Preventive Care Covered at 100% (no deductible) Covered at 100% (no deductible)
Primary Care Provider
Office Visit 80%* 70%* $20 copay $40 copay
Specialist Office Visit 80%* 70%* $35 copay $70 copay
Telemedicine 80%* 80%* $15 copay

Inpatient Hospital Services 80%* 70%* 80%* 70%*
Outpatient Hospital Services 80%* 70%* 80%* 70%*
Urgent Care 80%* 70%* $35 copay $70 copay
Emergency Room 80% after Enhanced deductible $100 copay (waived if admitted)
Out-of-Network Out-of-Network

Deductible per Benefit Period
(Individual/Family) $12,500/$25,000 $7,500/$15,000
Coinsurance 50%* 50%*

Out-of-Pocket Maximum
(Excludes Deductible) $12,500/$25,000 $5,000/$10,000
Primary Care Provider
Office Visit 50%* 50%*
Specialist Office Visit 50%* 50%*
Telemedicine Not covered Not covered
Inpatient Hospital Services 50%* 50%*
Outpatient Hospital Services 50%* 50%*
Urgent Care 50%* 50%*
Emergency Room 80% after Enhanced deductible $100 copay (waived if admitted)

Retail Pharmacy (up to a 30-day supply)
Retail Pharmacy Generic: $10 | Formulary Brand: $35 |
(30-day supply) 80%* Non-Formulary Brand: $65
Mail Order Pharmacy Generic: $20 | Formulary Brand: $70 |
(90-day supply) 80%* Non-Formulary Brand: $130

*After deductible

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