Page 9 - GESMN 2019 Benefits Enrollment Guide

Preventive Care Covered at 100%

Preventive care is key to staying healthy, which is why we pay 100% of the cost of preventive care visits. There is no
deductible to meet. We encourage you to take advantage of this benefit.

Medical Benefits
For a listing of out-of-network benefits, please see the medical plan documents.

$2,700 Deductible Plan $3,000 Deductible Plan
with HSA with HSA
Annual deductible (copayments do not $2,700/person $3,000/person
apply towards the deductible) $5,400/family $6,000/family
$500 for employee $500 for employee
coverage coverage
$1,000 for employee + $1,000 for employee +
Health Savings Account (HSA) spouse coverage spouse coverage
Contributed by GESMN
$1,000 for employee + $1,000 for employee +
child(ren) coverage child(ren) coverage
$1,000 for family coverage $1,000 for family coverage
Coinsurance 100% 80%
$2,700/person $6,000/person
Annual Out-of-Pocket Maximum
$5,400/family $12,000/family
Office Visit/Exam 100% after deductible 80% after deductible
Convenience Care/Retail Health Clinic 100% after deductible 80% after deductible
Visit
Diagnostic X-Ray or Lab 100% after deductible 80% after deductible
Adult and Child Preventive Care 100% (no deductible) 100% (no deductible)
Emergency Room Visits 100% after deductible 80% after deductible
Urgent Care Visits 100% after deductible 80% after deductible
Inpatient Hospital 100% after deductible 80% after deductible
Mental Health and Substance Abuse 100% after deductible 80% after deductible
Chiropractic Services 100% after deductible 80% after deductible
Retail Prescription Drugs (30-Day Supply/90-day Mail Order, where applicable)
Generic
Formulary Brand Drugs 100% after deductible; no 80% after deductible; no
Non-Formulary Brand Drugs charge for preventive drugs charge for preventive drugs

Specialty Tier

Did You Know?

Some preventive medications are covered at 100% under both HSA options.
Call HealthPartners or contact benefits@gesmn.org for a complete list of
included drugs.

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