Page 7 - FY21_FOB_Guide_(New_Hire)

FOCUS ON BENEFITS 2021

Goodwill-Easter Seals Minnesota

HEALTH PLAN SUMMARY

Effective Jan. 1, 2021, two health plans will be offered through HealthPartners
Always use an in-network provider for highest
Preventive care is covered at 100% and no deductible applies. For other benefit levels from your plan. Our health plans
services, this plan requires a deductible before eligible services are paid at 80%. use the Open Access network for the 3500-80
and the Achieve network for the 2800-80 plan.

The amount the plan pays for covered services
$3,500-80% 2800-80
In-Network Open Access Achieve is based on the allowed amount. If an out-of-
network provider charges more than the
Deductible $3,500 /single $2,800 /single allowed amount, you may have to pay the
per calendar year $7,000/family $5,600/family
difference. Always use an in- network provider
Out of Pocket Max $5,500 /single $4,200 /single for the highest coverage of services.
per calendar year $11,000/family $8,400/family
Physician Services SUMMARY OF BENEFITS COVERAGE
Office visits, Urgent Care Clinic, Retail 80% after deductible 80% after deductible
Health Clinics, Chiropractic
Refer to your summary of benefit coverage
Preventive Services
Well child, Immunizations, Certain (SBC) for a more detailed explanation about
Prenatal Services, Screening You pay $0 You pay $0 your health plan benefits, including mail order
Mental/ prescriptions and other health services,
Behavioral/ 80% after deductible 80% after deductible
Substance Use including excluded medical services.
Outpatient
Ambulance 80% after deductible 80% after deductible HealthPartners has preventive medications to
avoid disease and maintain health that are
Hospital 80% after deductible 80% after deductible
available at either no cost or a $60 copay for
Prescription Drugs brand name medications. Please visit the
Retail GenericsPlusRx
Formulary generic website or call 800-883-2177 for more
Formulary brand 80% after deductible for 80% after deductible for information.
Non-formulary brand generic or brand. Non- generic or brand. Non-
formulary NOT COVERED formulary NOT COVERED
VALUE ADDED SERVICES
Mail Order GenericsPlusRx
Formulary generic Healthy Discounts
Formulary brand
Non-preferred brand Vision Discounts
Specialty 80% after deductible 80% after deductible Care Line Service: 800-551-0859.
virtuwell: www.virtuwell.com.
Convenience Clinics
Bi-Weekly Payroll Rates Babyline Service: 800-845-9297.
3500-80 Open Access 2800-80 Achieve
Status Behavioral Health Personalized Assistance Line
Non- (PAL): 952-883-5811 or 888-638-8787
Engaged Non-engaged Engaged
engaged
yumPower: www.yumPower.com.
Employee only $70.03 $93.10 $32.96 $56.04
Tobacco Cessation: 800-311-1052.
Employee +Spouse $201.60 $224.68 $120.03 $143.11
Travel Assistance: 800-872-1414.
Employee +Child(ren) $171.99 $195.07 $94.13 $117.21 OnTrackRx: www.healthpartners.com.
Family $294.61 $317.69 $173.95 $197.03

• Employees are eligible for engaged rates for 2021 if you qualified during the QUESTIONS?
2020 campaign; if newly hired after May 1, 2021; or if not currently
enrolled and electing medical under a qualifying life event. Call customer service at 952-883-5000 or visit
• Please review your summary of benefits document for more detailed www.healthpartners.com
coverage information.

6