2022 Ensign Benefits Guide

2022 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 / $1,0001 $1,5005 / $3,0001,5 $2,000 / $4,0001 Coinsurance (You Pay) 20% 20% 20% Calendar Year Out-of-Pocket Maximum Employee Only / Family $2,000 / $4,000 $5,0006 / $10,0006 $6,000 / $12,000 Health Savings Account (HSA) N/A You can contribute pre-tax dollars to an HSA through HealthEquity. IRS limits for 2022 are $3,650 (employee only) and $7,300 (family). You can contribute an additional $1,000 if you are age 55 or older in 2022. You can contribute pre-tax dollars to an HSA through HealthEquity. IRS limits for 2022 are $3,650 (employee only) and $7,300 (family). You can contribute an additional $1,000 if you are age 55 or older in 2022. NETWORK ONLY YOU PAY IN-NETWORK YOU PAY NETWORK ONLY YOU PAY Preventive Care Covered in full3 Covered in full3 Covered in full3 Telemedicine Doctor Visit Behavioral Health Visit Through Teladoc $20 copay $20 copay Through Teladoc 10%2 (Cost is $40 per visit) 10%2 (Cost is $40 per visit) Through Teladoc 10%2 (Cost is $40 per visit) 10%2 (Cost is $40 per visit) Telemedicine (text-based) Doctor Visit Through 98point6 FREE Through 98point6 $5 copay Through 98point6 $5 copay 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 copay2,7, then you pay 20% $500 copay2,7 then you pay 30% $500 copay2,7 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 copay2, then you pay 20% 20%2 20%2 20%2 20%2 20%2 Outpatient Treatment (PT, OT, ST) 20%2 20%2 20%2 Mental Health/Substance Abuse Inpatient Outpatient $500 copay then 20%2 $30 copay9 20%2 20%2 20%2 20%2 Pharmacy Retail Specified Preventive Drugs4 Generic Brand Formulary Brand Non-Formulary Specialty Drugs 30-day supply11 100% covered3 $10 copay3 $25 copay3 $40 copay3 20%3,8 up to $125 30-day supply11 100% covered3 $10 copay2 $25 copay2 $40 copay2 20%2,8 up to $125 30-day supply11 100% covered3 $10 copay2 $25 copay2 $40 copay2 20%2,8 up to $125 Pharmacy Mail Service Specified Preventive Drugs4 Generic Brand Formulary Brand Non-Formulary 90-day supply 100% covered3 $20 copay3 $50 copay3 $80 copay3 90-day supply 100% covered3 $20 copay2 $50 copay2 $80 copay2 90-day supply 100% covered3 $20 copay2 $50 copay2 $80 copay2 5) I n-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. 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. 10

RkJQdWJsaXNoZXIy NzQzMzY=