4. Health Insurance Benefits ScheduleMinnesota Public Employees Insurance Program (PEIP)
Adlrantaee Health Plan - HSA Compatible 2021-2022 Benefits Schedule
Benefit Provision
Cost Level 1 — You Pay
Cost Level 2 — You Pay
Cost Level 3 — You Pay
Cost Level 4 — You Pay
A. Preventive Care Services
• Routine medical exams, cancer screening
• Child health preventive services, routine
• immunizations
Nothing
Nothing
Nothing
Nothing
• Prenatal and postnatal care and exams
• Adult immunizations
• Routine eye and hearing.exams
B. Annual First Dollar Deductible
$1,500
$2,000
$3,000
$4,000
Combined Medical/Pharmacy (single coverage)
$2,800 per family member
$3,200 per family member
$4,800 per family member
$6,400 per family member
Combined Medical/Pharmacy (family coverage)
$3,000 per family
$4,000 per family
$6,000 per family
$8,000 per family
C. Office visits for Illnessllnjury, for Outpatient
Physical, Occupational or Speech Therapy,
and Urgent Care
• Outpatient visits in a physician's office
$45 copay per visit
$55 copay per visit
$105 copay per visit
$130 copay per visit
• Chiropractic services
annual deductible applies
annual deductible applies
annual deductible applies
annual deductible applies
• Outpatient mental health and chemical
dependency
• U ent Care clinic visits in & out of network
D. In -Network Convenience Clinics and Online
$0 copay
$0 copay
$0 copay
$0 copay
Care
annual deductible applies
annual deductible applies
annual deductible applies I
annual deductible applies
E. Emergency Care (in or out of network)
$150 copay
$150 copay
$150 copay
50% coinsurance
• Emergency care received in a hospital
annual deductible applies
annual deductible applies
annual deductible applies
annual deductible applies
eme ency room
F. Inpatient Hospital Copay
$400 copay
$650 copay
$1,500 copay
50% coinsurance
annual deductible applies
annual deductible applies
annual deductible applies
annual deductible applies
G. Outpatient Surgery Copay
$250 copay
$400 copay
$800 copay
50% coinsurance
annual deductible applies
annual deductible applies
annual deductible applies
annual deductible applies
H. Hospice and Skilled Nursing Facility
Nothing after
Nothing after
Nothing after
Nothing after
annual deductible
annual deductible
annual deductible
annual deductible
I. Prosthetics and Durable Medical Equipment
20% coinsurance
25% coinsurance
30% coinsurance
50% coinsurance
annual deductible applies
annual deductible applies
annual deductible applies
annual deductible applies
J. Lab (including allergy shots), Pathology,
and X-ray (not included as part of preventive
20% coinsurance
25% coinsurance
30% coinsurance
50% coinsurance
care and not subject to office visit or facility
annual deductible applies
annual deductible applies
annual deductible applies
annual deductible applies
copayments)
K. MRI/CT Scans
20% coinsurance
25% coinsurance
30% coinsurance
50% coinsurance
annual deductible applies
annual deductible applies
annual deductible applies
annual deductible applies
L. Other expenses not covered in A — K
above, including but not limited to:
• Ambulance
• Home Health Care
• Outpatient Hospital Services (non-surgical)
20% coinsurance
25% coinsurance
30% coinsurance
50% coinsurance
• Radiation/chemotherapy
annual deductible applies
annual deductible applies
annual deductible applies
annual deductible applies
• Dialysis
• Day treatment for mental health and
chemical dependency
• Other diagnostic or treatment related
out atient services
M. Prescription Drugs
$30 tier one
$30 tier one
$30 tier one
$30 tier one
30 -day supply of Tier 1, Tier 2, or Tier 3
$50 tier two
$50 tier two
$50 tier two
$50 tier two
prescription drugs, including insulin; or a
$75 tier three
$75 tier three
$75 tier three
$75 tier three
3 -cycle supply of oral contraceptives.
annual deductible applies
annual deductible applies
annual deductible applies
annual deductible applies
N. Plan Maximum Out-of-pocket Expense**
$3,000
$3,000
$4,000
$5,000
(including prescription drugs) Single Coverage
$5,000 per family member
$5,000 per family member
$6,900 per family member
$6,900 per family member
Family Coverage
$6,000 per family
$6,000 per family
$8,000 per family
$10,000 per family
This chart applies only to in -network coverage. Point of Service coverage is available only to members whose permanent residence is both outside the Slate of Minnesota and the Advantage Plan's service area This
category includes employees temporarily residing outside Minnesota on temporary assignment or paid leave [including sabbatical leaves] and college students. It is also available to dependent children and spouses
permanently residing outside the service area. Members pay a S1, 500 single or S3, 000 Family deductible (separate and distinct from the deductibles listed in section B above) and 30% coinsurance that will apply to the
out-of-pocket maximums described in section N above. Members pay the drug copayment described at section M above to the out-of-pocket maximum described at section N. This benefit most be requested.
The PEIP Advantage Plans offer a standard set of benefits regardless of the selected carrier. There are some differences in the way each carrier administers the benefits, including the transplant benefits, in the
referral and diagnosis coding patterns of primary care clinics, and in the definition of Allowed Amount.
"The family Deductible is the maximum amount that a family must pay in deductible expenses in any one calendar year. The family Deductible is not the amount of expenses a family must incur before any family
member can receive benefits, Individual family members only need to satisfy their individual deductible once to be eligible for benefits Once the family Deductible has been met deductible expenses for the family are
waived for the balance of the year. **The family Out -of -Pocket Maximum is the maximum amount that a family must pay in any one calendar year. The per -family member embedded Out -of -Pocket Maximum is the
maximum amount that a family must pay in any one calendar year on behalf of any individual family member.