2020 Ensign Benefits Guide

CA Residents San Diego County Residents Copay 5000 PPO 5000 with HSA Kaiser CA HMO 2000 w/ HSA SIMNSA Baja CA Premier Access HMO $5,000 5 / $10,000 1,5 $5,000 5 / $10,000 1,5 $2,000 / $4,000 1 N/A 20% 20% 20% None $7,000 6 / $14,000 6 $6,550 6 / $13,100 6 $3,425 / $6,850 $6,350 / $12,700 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. N/A IN-NETWORK YOU PAY IN-NETWORK YOU PAY NETWORK ONLY YOU PAY NETWORK ONLY YOU PAY Covered in full 3 Covered in full 3 Covered in full 3 Covered in full $25 copay $50 copay 10% 2 (Cost is $40 per visit) 20% 2 (Cost is $80 per visit) 20% 2 N/A N/A N/A $45 copay 20% 2 20% 2 $5 copay $75 copay 20% 2 20% 2 $5 copay $75 copay 20% 2 20% 2 $25 copay (provider in Mexico) $50 copay (provider outside Mexico) $500 copay 2,7 then you pay 30% $500 copay 2,7 then you pay 30% 20% 2 $250 copay 7 20% 2 20% 2 20% 2 Covered in full 20% 2 20% 2 20% 2 Covered in full 20% 2 20% 2 20% 2 20% 2 20% 2 20% 2 Covered in full Covered in full 20% 2 20% 2 20% 2 $10 copay 20% 2 $75 copay 9 20% 2 20% 2 20% 2 20% 2 Covered in full $5 copay 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 30-day supply 100% covered 3 $10 copay 2 $30 copay 2 N//A 20% 2 up to $125 30-day supply 100% covered $5 copay $5 copay $5 copay $5 copay 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 2 100- day supply 100% covered 3 $20 copay 2 $60 copay 2 N/A 90-day supply N/A N/A N/A N/A 6) In-network calendar year out-of-pocket maximum is separate from out-of-network calendar year out-of-pocket maximum and does not cross accumulate. Refer to the Summary of Benefits and Coverage (SBC) for the plan for information on out-of-network out-of-pocket maximum amounts on www.ensignbenefits.com . 7) Emergency Room copay waived if admitted. 8) May be available at CVS retail pharmacy or Pharmacy Mail Service if authorized. Note that any specialty drug discounts through copay cards or coupons will not apply towards the calendar year deductible our out-of-pocket maximum. 9) Intensive outpatient: $250 copay per visit plus 20% after calendar year deductible. 11