Page 9 - 1800Flowers 2022 Benefits Guide

Medical Plans

For more information regarding the services provided by these plans, please refer to the
Summary of Benefits Coverage (SBCs) found on the Benefits Marketplace portal.

$4,500/$9,000 Ded. Plan w/HSA $6,000/$12,000 Ded. Plan w/HSA
In-Network Out-of-Network In-Network Out-of-Network
Health Well-being Dollars (HSA)
For You $500 $500
For Your Spouse $500 $500
Annual Deductible
Single $4,500 $9,000 $6,000 $10,000
Family $9,000 $18,000 $12,000 $20,000
Coinsurance 70%* 50%* 100%* 70%*
Annual Out-of-Pocket Maximum (includes deductible)
Single $6,000 $12,000 $6,000 $12,000
Family $12,000 $24,000 $12,000 $24,000
Deductible and Out-of-Pocket Embedded Embedded
Maximum Type**
Services
Preventive Care 100% 50%* 100% 70%*
Doctor’s Office Visits (non-preventive) 70%* 50%* 100%* 70%*
Telemedicine 70%* Not covered 100%* Not covered
Outpatient Surgery, Diagnostic and 70%* 50%* 100%* 70%*
Therapeutic Services (CAT Scans, PET
Scans, MRI)
Hospital Stay 70%* 50%* 100%* 70%*
Emergency Room (when a true 70%* 70%* 100%* 100%*
emergency)
Urgent Care 70%* 70%* 100%* 100%*
Retail Rx Patient pays after deductible: Patient pays after deductible:
Tier 1 (generic) $10* 0%*
Tier 2 (brand-preferred) 30%* ($25 min / $75 max) 0%*
Tier 3 (brand non-preferred) 40%* ($50 min / $100 max) 0%*

**Embedded deductible: This means that deductible expenses for each covered family member are capped at the individual deductible amount.
For example: You, your wife and daughter are on the $3,000 Deductible Plan w/HSA, which has a $6,000 family deductible when using an in-network provider. Your
daughter incurs $3,000 in medical expenses, which means her deductible is met. The insurance company will help pay for any additional medical bills through coinsurance
for your daughter that year, even though the family deductible of $6,000 has not been met yet. The same rule applies to the Out-of-Pocket Maximum amounts.
Note: When you are enrolled in any of the 1-800-FLOWERS.COM, Inc. medical plans and see an in-network provider, preventive care is covered at 100% with no deductible.
$6,000 Ded. Plan w/HSA: Certain medications that are considered preventive will bypass the deductible and match the pharmacy cost sharing schedule as the other medical
plan options. For a full list of these prescriptions please consult with CVS Caremark.

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