Page 6 - PRO_2023 Client Benefits Guide

Medical (Cont’d)
Following is a high-level overview of the coverage available. For complete coverage details, please refer to the Summary Plan Description (SPD).
Key Medical Benefits
Plan 4 - MN 2000-0% H.S.A. - PPO
Plan 5 - MN 3000-25% H.S.A. - PPO
Plan 6 - MN 4500-20% H.S.A. - PPO
Plan 7 - MN 6650-0% H.S.A. - PPO
In-Network
Out-of-Network1
In-Network
Out-of-Network1
In-Network
Out-of-Network1
In-Network
Out-of-Network1
Deductible (per Calendar year)
Individual / Family
$2,000 2 / $4,000 2
$4,000 / $8,000
$3,000 3 / $6,000 3
$6,000 / $12,000
$4,500 3 / $9,000 3
$9,000 / $18,000
$6,650 3 / $13,300 3
$13,300 / $26,600
Out-of-Pocket Maximum (per Calendar year)
Individual / Family
$2,000 / $4,000
$9,000 / $18,000
$6,500 / $13,500
$19,500 / $39,000
$6,000 / $13,000
$19,500 / $39,000
$6,650 / $13,300
$20,250 / $40,500
Covered Services
Office Visits
(physician/specialist)
0%* / 0%*
50% */ 50%*
25%* / 25%*
50%* / 50%*
20% / 20%*
50%* / 50%*
0%* / 0%*
50%* / 50%*
Virtual Visits
0%*
50% *
25%* / 25%*
50%* / 50%*
20%*
50%*
0%*
50%*
Routine Preventive Care
0%
Well Child Care: 0% / Other Services: 50%*
0%
Well Child Care: 0% / Other Services: 50%*
0%
Well Child Care: 0% / Other Services: 50%*
0%
Well Child Care: 0% / Other Services: 50%*
Outpatient Diagnostic
(lab/X-ray)
0%* / 0%*
50% *
25%*
50%*
20% / 20%*
50%*
0%*
50%*
Complex Imaging
0%*
50% *
25%*
50%*
20%*
50%*
0%*
50%*
Chiropractic
0%*
50%*
25%*
50%*
20%*
50%*
0%*
50%*
Ambulance
0%*
25%*
20%*
0%*
Emergency Room
0%*
25%*
20%*
0%*
Urgent Care Facility
0%*
25%*
20%*
0%*
Inpatient Hospital Stay
0%*
50%*
25%*
50%*
20%*
50%*
0%*
50%*
Outpatient Surgery
0%*
50%*
25%*
50%*
20%*
50%*
0%*
50%*
Prescription Drugs
(Generic / Preferred Brand / Non-Preferred Brand / Specialty Preferred / Specialty Non-Preferred)
(Generic / Brand / Non-Formulary / Specialty)
(Generic / Preferred Brand / Non-Preferred Brand / Specialty Preferred / Specialty Non-Preferred)
Retail Pharmacy
(30-day supply)
0%* / 0%*/ 0%* / 0%* / 0%*
50%*
Preventive: No charge / 25%* / 45%* / 25% to $200* / 45%*
50%*
20%* / 20%* / 40%* / 20%* to no more than $200 / 40%*
50%*
0%* / 0%* / 0%* / 0%* / 0%*
50%*
Mail Order
(90-day supply)
0%* / 0%*/ 0%*
Not covered
25%* / 25%* / 45%*
Not covered
20%* / 20%* / 40%*
Not covered
0%* / 0%* / 0%*
Not covered
Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying.
*Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay.
To be eligible for the HSA, you cannot be covered through Medicare Part A or Part B or TRICARE programs. See the plan documents for full details. 1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.
2. Non-Embedded - family deductible applies before claims are paid.
3. Embedded - individual deductible applies for each member up to family deductible.
4. Plan details are for the Passport network only. Please refer to the Summary of Benefit and Coverage for the full plan details of all other networks.
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