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FOCUS ON BENEFITS 2020

Goodwill-Easter Seals Minnesota

HEALTH PLAN SUMMARY

GESMN offers two health plans through HealthPartners
Preventive care is covered at 100% and no deductible applies. For other
services, this plan requires a deductible before eligible services are paid at 80%.

$3,500-80% 2800-80
In-Network Open Access Achieve
Deductible $3,500 /single $2,800 /single Always use an in-network provider for highest
per calendar year $7,000/family $5,600/family benefit levels from your plan. Our health plans
Out of Pocket Max $5,500 /single $4,200 /single use the Open Access network for the 3500-80
per calendar year $11,000/family $8,400/family
and the Achieve network for the 2800-80 plan.
Physician Services
Office visits, Urgent Care Clinic, Retail 80% after deductible 80% after deductible
Health Clinics, Chiropractic The amount the plan pays for covered services
Preventive Services is based on the allowed amount. If an out-of-
Well child, Immunizations, Certain network provider charges more than the
Prenatal Services, Screening You pay $0 You pay $0
allowed amount, you may have to pay the
Mental/
Behavioral/ 80% after deductible 80% after deductible difference. Always use an in- network provider
Substance Use for the highest coverage of services.
Outpatient
Ambulance 80% after deductible 80% after deductible
SUMMARY OF BENEFITS
Hospital 80% after deductible 80% after deductible
Prescription Drugs COVERAGE
Retail GenericsPlusRx
Formulary generic Refer to your summary of benefit coverage
Formulary brand 80% after deductible for 80% after deductible for
Non-formulary brand generic or brand. Non- generic or brand. Non- (SBC) for a more detailed explanation about
formulary are 60% after formulary are 60% after your health plan benefits, including mail order
deductible deductible
prescriptions and other health services,
Mail Order GenericsPlusRx
Formulary generic including excluded medical services.
Formulary brand
Non-preferred brand
Specialty 80% after deductible 80% after deductible

Bi-Weekly Payroll Rates
3500-80 Open Access 2800-80 Achieve
Status
Non-
Engaged Non-engaged Engaged
engaged
Employee only $68.71 $91.79 $31.92 $54.99
Employee +Spouse $198.71 $221.79 $117.75 $140.83
Employee +Child(ren) $169.23 $192.30 $91.95 $115.02

Family $290.33 $313.41 $170.58 $193.66
QUESTIONS?
• Employees are eligible for engaged rates for 2020 if you qualified during the
recent campaign; if newly hired after May 1, 2019; or if not currently Call customer service at 952-883-5000 or visit
enrolled in GESMN benefits and electing medical at Open Enrollment.
www.healthpartners.com
• Please review your summary of benefits document for more detailed
coverage information.

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