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NationalONE Plan HRA Empower HSA <br />NationalONE Plan <br />Annual Deductible single/family $2,500/$5,000 $2,800/$7,600 <br />Co-Insurance % 100% 100% <br />Annual Out-of-Pocket Max single/family $2,500/$5,000 $2,800/$7,600 <br />Office Visits and Urgent Care <br />Preventive Care Office Visit Co-Pay $0 $0 <br />Regular Office Visit Co-Pay 100% after deductible 100% after deductible <br />Specialist Visit Co-Pay 100% after deductible 100% after deductible <br />Urgent Care Co-Pay 100% after deductible 100% after deductible <br />Hospital Coverage <br />Emergency Room Co-Pay 100% after deductible 100% after deductible <br />Prescription Coverage <br />Retail Generic/Brand/Non-Preferred 80% ($10 minimum, <br />$25 maximum)100% after deductible <br />Open Access Monthly Premium Monthly Premium <br />Employee Only $782.53 $717.47 <br />Employee + Spouse $1,643.99 $1,507.30 <br />Employee + Children $1,565.76 $1,435.57 <br />Employee + Family $2,035.51 $1,866.27 <br />Perform Monthly Premium Monthly Premium <br />Employee Only $766.88 $703.12 <br />Employee + Spouse $1,611.11 $1,477.16 <br />Employee + Children $1,534.44 $1,406.86 <br />Employee + Family $1,994.80 $1,828.95 <br />Achieve Monthly Premium Monthly Premium <br />Employee Only $735.58 $674.42 <br />Employee + Spouse $1,545.35 $1,416.86 <br />Employee + Children $1,471.81 $1,349.44 <br />Employee + Family $1,913.38 $1,754.30 <br />January 1, 2021 <br />Benefit Details <br />HealthPartners Plans <br />CITY OF ORONO MEDICAL PLAN OPTION 1 - HEALTHPARTNERS <br />274 <br />274