Page 7 - Excelligence 2022 Benefit Guide

Medical and pharmacy coverage
Medical Plan Provisions
PPO Plan with HRA
In-Network
$1,000/$2,000
Out-of-Network
HDHP with HSA Plan
In-Network
N/A
Out-of-Network
Traditional PPO Plan
In-Network
N/A
Out-of-Network
$3,000/ $6,000
$9,000/ $18,000
$3,000/ $5,800/ $6,000 $11,800
$1,000/ $3,000
$3,000/ $9,000
$5,000/ $10,000
$15,000/ $30,000
50%*
$5,000/ $15,000/ $10,000 $30,000
$5,000/ $10,000
$15,000/ $30,000
Covered at 100%
Covered at 100%
50%*
Covered at 100%
50%*
$30 copay
50%*
20%* 50%*
$35 copay
50%*
$40 copay
50%*
20%* 50%*
20%* 50%*
$35 copay
50%*
$20 copay
Not covered
20%* Not covered
$10 copay
Not covered
30%*
50%*
30%*
50%*
30%*
50%*
30%*
50%*
50%*
20%* 50%*
30%*
20%* 50%*
30%*
50%*
Retail Pharmacy (up to a 30-day supply)
$30 copay
$20
30%*
50%*
Not covered
Not covered
20%* 50%*
$20* Not covered
$35 copay
$20
50%*
20%*
$150 copay
(waived if admitted), then 30%*
Not covered
$45
$45* Not covered
$45
Not covered
$75
Not covered
$75* Not covered
$75
Not covered
Retail Pharmacy (up to a 90-day supply)
30% up to $250
$45
Not covered
Not covered
30% up to $250*
Not covered
30% up to $250
$45
Not covered
Not covered
$135
Not covered
Not covered
$45* Not covered
$135* Not covered
$45* Not covered
$135* Not covered
$225* Not covered
$135
$45
$225
Not covered
$225
Not covered
$225* Not covered
$225
Not covered
Mail Order Pharmacy (90-day supply)
$45
Not covered
$135
Not covered
$135
Not covered
$225
Not covered
Not covered
Company contribution to HRA
(Individual/Family)
Annual Deductible
(Individual/Family)
Out-of-Pocket Maximum
(Includes Deductible)
Preventive Care
Primary Care Provider Office Visit
Specialist Office Visit Telemedicine
X-Ray and Lab
Inpatient Hospital Services Outpatient Hospital Services Urgent Care
Emergency Room
Generic
Brand Preferred Brand Non-Preferred
Specialty
Generic
Brand Preferred Brand Non-Preferred
Generic
Brand Preferred
Brand Non-Preferred
*After deductible
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