2020 Ensign Benefits Guide

2020 Medical Plans At-a-Glance 1) The family deductible must be met before any person receives benefits. 2) After calendar year deductible. 3) Calendar year deductible waived. 4) As specified in the essential drug list. Plan Feature EPO 500 PPO 1500 with HSA EPO 2000 with HSA Calendar Year Deductible Employee Only / Family $500 / $1,000 1 $1,500 5 / $3,000 1,5 $2,000 / $4,000 1 Coinsurance (You Pay) 20% 20% 20% Calendar Year Out-of-Pocket Maximum Employee Only / Family $2,000 / $4,000 $5,000 6 / $10,000 6 $6,000 / $12,000 Health Savings Account (HSA) N/A You can contribute pre-tax dollars to an HSA through HealthEquity. IRS limits for 2020 are $3,550 (employee only) and $7,100 (family). You can contribute an additional $1,000 if you are age 55 or older in 2020. You can contribute pre-tax dollars to an HSA through HealthEquity. IRS limits for 2020 are $3,550 (employee only) and $7,100 (family). You can contribute an additional $1,000 if you are age 55 or older in 2020. NETWORK ONLY YOU PAY IN-NETWORK YOU PAY NETWORK ONLY YOU PAY Preventive Care Covered in full 3 Covered in full 3 Covered in full 3 Telemedicine Doctor Visit Behavioral Health Visit $20 copay $40 copay 10% 2 (Cost is $40 per visit) 20% 2 (Cost is $80 per visit) 10% 2 (Cost is $40 per visit) 20% 2 (Cost is $80 per visit) PCP Office Visit $30 copay 20% 2 20% 2 Specialist Office Visit $50 copay 20% 2 20% 2 Urgent Care $50 copay 20% 2 20% 2 Emergency Room $500 copay 2,7 , then you pay 20% $500 copay 2,7 then you pay 30% $500 copay 2,7 then you pay 30% Diagnostic Testing 20% 2 20% 2 20% 2 Outpatient X-ray and Lab 20% 2 20% 2 20% 2 Hospitalization Inpatient Semi-Private Room Inpatient Physician $500 copay 2 , then you pay 20% 20% 2 20% 2 20% 2 20% 2 20% 2 Outpatient Treatment (PT, OT, ST) then you pay 20% 20% 2 20% 2 Mental Health/Substance Abuse Inpatient Outpatient $500 copay then 20% 2 $50 copay 9 20% 2 20% 2 20% 2 20% 2 Pharmacy Retail Specified Preventive Drugs 4 Generic Brand Formulary Brand Non-Formulary Specialty Drugs 30-day supply 100% covered 3 $10 copay 3 $25 copay 3 $40 copay 3 20% 3,8 up to $125 30-day supply 100% covered 3 $10 copay 2 $25 copay 2 $40 copay 2 20% 2,8 up to $125 30-day supply 100% covered 3 $10 copay 2 $25 copay 2 $40 copay 2 20% 2,8 up to $125 Pharmacy Mail Service Specified Preventive Drugs 4 Generic Brand Formulary Brand Non-Formulary 90-day supply 100% covered 3 $20 copay 3 $50 copay 3 $80 copay 3 90-day supply 100% covered 3 $20 copay 2 $50 copay 2 $80 copay 2 90-day supply 100% covered 3 $20 copay 2 $50 copay 2 $80 copay 2 5) In-network calendar year deductible is separate from out-of-network calendar year deductible and does not cross accumulate. Refer to the Summary of Benefits and Coverage (SBC) for the plan for information on out-of-network deductible amounts on www.ensignbenefits.com . 10