Page 8 - Winsight 2021 Benefit Guide

Medical and pharmacy

coverage (continued)

$1,500 PPO Plan $500 PPO Plan
Plan Provision
In-Network Out-of-Network In-Network Out-of-Network

Winsight Contribution to HSA
(Individual / Family) N/A N/A
Annual Deductible $1,500 / $4,500 $3,000 / $9,000 $500/$1,500 $1,000/$3,000
(Individual/Family) embedded embedded embedded embedded
Out-of-Pocket Maximum $5,000/$10,000 $10,000/$20,000 $3,000/$6,000 $6,000/$12,000
(Includes Deductible)

Coinsurance 80%* 60%* 90%* 70%*
Preventive Care 100% 60%* 100% 70%*
Primary Care Provider $30 Copay 60%* $25 Copay 70%*
Office Visit
Specialist Office Visit $75 Copay 60%* $50 Copay 70%*
X-Ray and Lab 80%* 60%* 90%* 70%*
MRIs, MRAs, CAT Scans, and 80%* 60%* 90%* 70%*
PET Scans
Inpatient Hospital Services 80%* $300 admission; 60%* 90%* $300/admission; 70%*

Outpatient Hospital Services 80%* 60%* 90%* 70%*
Urgent Care 80%* 60%* 90%* 70%*
Emergency Room $250 Copay (waived if admitted) $250 Copay (waived if admitted)
Retail pharmacy (up to a 30-day supply)
Preferred Generic No Charge No Charge

Non-Preferred Generic $10 Copay $10 Copay
Preferred Brand $50 Copay Copay + charges over $50 Copay Copay + charges
in-network allowed over in-network
Non-Preferred Brand $100 Copay amount $100 Copay allowed amount

Preferred Specialty $150 Copay $150 Copay
Non-Preferred Specialty $250 Copay $250 Copay
Mail Order Pharmacy (90-day supply)
Preferred Generic No Charge No Charge
Non-Preferred Generic $20 Copay $20 Copay
Preferred Brand $100 Copay Copay + charges over $100 Copay Copay + charges
in-network allowed over in-network
Non-Preferred Brand $200 Copay amount $200 Copay allowed amount
Preferred Specialty N/A N/A
Non-Preferred Specialty N/A N/A
*After deductible

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