11-09-2020 Council Packet - Laserfiche WebLink

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Carrier:HealthPartners HealthPartners Plan:$2500 HDHP.HRA $2800 HDHP.HSA RX PLUS In-Network Plan Design Features Lifetime Maximum Unlimited Unlimited Annual Maximum N/A N/A Deductible CY $2,500/person $5,000/family $2,800/person $5,600/family Coinsurance 100/0%100/0% Medical Out-of-Pocket Max (includes Medical & Rx) $2,500/person $5,000/family $2,800/person $5,600/family Preventive Care 100% coverage 100% coverage Office Visit/Urgent Care 100% after deductible 100% after deductible Convenience/Retail Care Clinic 100% coverage 100% after deductible Lab & Pathology 100% after deductible 100% after deductible X-ray & Other Imaging 100% after deductible 100% after deductible Inpatient Hospitalization 100% after deductible 100% after deductible Outpatient Hospitalization 100% after deductible 100% after deductible Emergency Room Facility 100% after deductible 100% after deductible Prescription Drugs (Rx) Retail - 1 month supply Preferred Generic, Preferred Brand & Non-Preferred: 80/20% with a min $10 and max $25 copay/script Copayment for 1-month supply of Select Preventive Medications Generic: $12.00 Brand: $45.00 otherwise: 100% after deductible Mail Order - 3 month supply Preferred Generic, Preferred Brand & Non-Preferred: 80/20% with a min $20 and max $50 copay/script Copayment for 3-month supply of Select Preventive Medications Generic: $24.00 Brand: $90.00 otherwise: 100% after deductible Specialty - Retail 80/20% capped at $200/script/month 100% after deductible Open Access Employee $805.50 $739.50 Employee + Child(ren)$1,610.00 $1,479.00 Employee + Spouse $1,690.50 $1,553.00 Family $2,093.00 $1,922.50 Perform Employee $789.00 $725.00 Employee + Child(ren)$1,578.00 $1,449.50 Employee + Spouse $1,656.50 $1,522.00 Family $2,051.00 $1,884.00 Achieve Employee $773.00 $710.00 Employee + Child(ren)$1,545.50 $1,420.00 Employee + Spouse $1,623.00 $1,490.50 Family $2,009.00 $1,845.50 *Rates above include HealthPartners EAP = $1.00/pmpm NETWORK DEFINITIONS: Open Access: Open Access Perform: Open Access network - without Mayo Achieve: HealthPartners and Park Nicollet Care systems, HealthPartners Family of Care, Northwest Alliance Partners, an City of Orono Medical Plan Options & Rates with EAP Band C January 1, 2020 The information contained herein subject to the disclosures and disclaimers on the final page of this illustration Preferred Rx formulary This analysis is an outline of the coverage proposed by the carrier's, based on information provided by your company. It does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request. 272 272