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FOCUS ON BENEFITS 2022

Goodwill-Easter Seals Minnesota

HEALTH PLAN SUMMARY

Effective Jan. 1, 2022, 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 services, benefit levels from your plan. Our health plans
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.

$3,500-80% $2,800-80% The amount the plan pays for covered services
In-Network Open Access Achieve is based on the allowed amount. If an out-of-
Deductible $3,500 /single $2,800 /single network provider charges more than the
per calendar year $7,000/family $5,600/family allowed amount, you may have to pay the
Out of Pocket Max $5,500 /single $4,200 /single difference. Always use an in-network provider
per calendar year $11,000/family $8,400/family for the highest coverage of services.
Physician Services
Office visits, Urgent Care Clinic, Retail 80% after deductible 80% after deductible
Health Clinics, Chiropractic SUMMARY OF BENEFITS
Preventive Services COVERAGE
Well child, Immunizations, Certain
Prenatal Services, Screening You pay $0 You pay $0 Refer to your summary of benefit coverage
Mental/
Behavioral/ 80% after deductible 80% after deductible (SBC) for a more detailed explanation about
Substance Use your health plan benefits, including mail order
Outpatient
Ambulance 80% after deductible 80% after deductible prescriptions and other health services,
including excluded medical services.
Hospital 80% after deductible 80% after deductible
Prescription Drugs VALUE ADDED SERVICES
Retail GenericsPlusRx
Formulary generic
Formulary brand 80% after deductible for 80% after deductible for Healthy discounts
Non-formulary brand generic or brand. Non- generic or brand. Non-
formulary NOT COVERED formulary NOT COVERED Vision discounts
Care line service: 800-551-0859
Mail Order GenericsPlusRx
Formulary generic virtuwell: www.virtuwell.com
Formulary brand
Non-preferred brand Convenience clinics
Specialty 80% after deductible 80% after deductible Babyline service: 800-845-9297
Behavioral health personalized assistance line
(PAL): 952-883-5811 or 888-638-8787
Bi-Weekly Payroll Rates yumPower: www.yumPower.com
3500-80 Open Access 2800-80 Achieve Tobacco cessation: 800-311-1052
Status
Non-
Engaged Non-engaged Engaged engaged Travel assistance: 800-872-1414

Employee only $70.02 $93.10 $32.96 $56.04 OnTrackRx: www.healthpartners.com
Employee + Spouse $201.60 $224.68 $120.03 $143.11
Employee + Child(ren) $171.99 $195.07 $94.13 $117.21
Family $294.61 $317.69 $173.95 $197.03 QUESTIONS?

• Employees are eligible for engaged rates for 2022 if you qualified during the Call customer service at 952-883-5000 or visit
recent campaign; if benefit eligible July 1, 2021 or later; or if not currently www.healthpartners.com.
enrolled in GESMN benefits and electing medical at open enrollment.
• Please review your summary of benefits document for more detailed
coverage information.

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