Small Group Plan Options

2020

1

Health Tradition For Employers Network Service Area

2

Health Tradition East Network Service Area

2020 Small Group HMO Plans

Endnotes on last page.

Covered Services (Calendar Year

Benefits)

Platinum 500

w/Copay

Platinum 1000

w/Copay

Gold 1000/80

w/Copay Gold

1500/80 Gold

2500/70 w/Copay

Silver 2000/70 w/Copay

Silver 2000/70

Annual Deductible Individual/Family†

$500/ $1,000

$1,000/ $2,000

$1,000/ $2,000

$1,500/ $3,000

$2,500/ $5,000

$2,000/ $4,000

$2,000/ $4,000

Annual Out-of-Pocket Maximum Individual/Family†

$1,500/ $3,000

$3,000/ $6,000

$4,500/ $9,000

$4,000/ $8,000

$5,500/ $11,000

$8,150/ $16,300

$8,150/ $16,300

Preventive Care* 100% Coverage

100% Coverage

100% Coverage

100% Coverage

100% Coverage

100% Coverage

100% Coverage

Deductible applies unless otherwise noted (Copays do not apply to deductible)

Office Visits Primary/Specialist

$25/$50 Copay

Deductible NA

$20/$40 Copay

Deductible NA

$40/$90 Copay

Deductible NA 20%

$45/$90 Copay

Deductible NA

$70/$150 Copay

Deductible NA 30%

Chiropractic $25 Copay Deductible NA

$20 Copay Deductible NA

$40 Copay Deductible NA 20% $45 Copay

Deductible NA $70 Copay

Deductible NA 30%

Urgent Care** $75 Copay Deductible NA

$75 Copay Deductible NA

$125 Copay Deductible NA 20% $150 Copay

Deductible NA $200 Copay

Deductible NA 30%

Emergency Room Services** (Deductible, Copay, then coinsurance)

$150 Copay then 20%

$175 Copay then 20%

$250 Copay then 20%

$250 Copay then 20%

$300 Copay then 30%

$300 Copay then 30%

$250 Copay then 30%

Ambulance 20% 20% 20% 20% 30% 30% 30%

Hospitalization Inpatient/outpatient 20% 20% 20% 20% 30% 30% 30%

Outpatient Lab/Radiology 20% 20% 20% 20% 30% 30% 30%

Durable Medical Equipment 20% 20% 20% 20% 30% 30% 30%

Skilled Nursing Facilities 20% 20% 20% 20% 30% 30% 30%

Home Health Care 20% 20% 20% 20% 30% 30% 30%

Rehabilitation PT/OT/ST max of 20 visits each/year

20% 20% 20% 20% 30% 30% 30%

Prenatal/Postnatal Care & Delivery 20% 20% 20% 20% 30% 30% 30%

Mental/Behavioral Health, Outpatient

$25 Copay Deductible NA

$20 Copay Deductible NA

$40 Copay Deductible NA 20% $45 Copay

Deductible NA $70 Copay

Deductible NA 30%

Mental/Behavioral Health, Inpatient 20% 20% 20% 20% 30% 30% 30%

Prescription Drugs

G=Generic B=Brand N=Non-formulary S=Specialty

Deductible NA

$5 G $30 B $60 N $120 S

Deductible NA

$5 G $30 B $60 N $120 S

Deductible NA

$10 G $50 B 40% N 20% S

Deductible NA

$10 G $50 B 40% N 20% S

Deductible NA

$10 G $50 B 40% N 20% S

Deductible NA

$15 G $70 B 40% N 40% S

Deductible NA

$15 G $70 B 40% N 20% S

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2020 Small Group HMO Plans Plans in blue are qualified high-deductible plans compatible with Health Savings Accounts.

Endnotes on last page.

Covered Services

(Calendar Year Benefits)

Silver 3000/80 w/Copay

Silver 5000/80 w/Copay

Bronze 7750/60 w/Copay

Gold HDHP

100

Silver HDHP

100

Bronze HDHP

100

Annual Deductible Individual/Family†

$3,000/ $6,000

$5,000/ $10,000

$7,750/ $15,500

$3,000/ $6,000

$5,500/ $11,000

$6,900/ $13,800

Annual Out-of-Pocket Maximum Individual/Family†

$8,150/ $16,300

$8,150/ $16,300

$8,150/ $16,300

$3,000/ $6,000

$5,500/ $11,000

$6,900/ $13,800

Preventive Care* 100% Coverage

100% Coverage

100% Coverage

100% Coverage

100% Coverage

100% Coverage

In addition to meeting the deductible, member pays

Office Visits Primary/Specialist

$65/$150 Copay

Deductible NA

$60/$150 Copay

Deductible NA

$75/$150 Copay

Deductible NA 0% 0% 0%

Chiropractic $65 Copay Deductible NA

$60 Copay Deductible NA

$50 Copay Deductible NA 0% 0% 0%

Urgent Care** $200 Copay Deductible NA

$200 Copay Deductible NA 40% 0% 0% 0%

Emergency Room Services** (Deductible, Copay, then coinsurance)

$300 Copay then 20%

$300 Copay then 20% 40% 0% 0% 0%

Ambulance 20% 20% 40% 0% 0% 0%

Hospitalization Inpatient/outpatient 20% 20% 40% 0% 0% 0%

Outpatient Lab/Radiology 20% 20% 40% 0% 0% 0%

Durable Medical Equipment 20% 20% 40% 0% 0% 0%

Skilled Nursing Facilities 20% 20% 40% 0% 0% 0%

Home Health Care 20% 20% 40% 0% 0% 0% Rehabilitation PT/OT/ST max of 20 visits each/year

20% 20% 40% 0% 0% 0%

Prenatal/Postnatal Care & Delivery 20% 20% 40% 0% 0% 0%

Mental/Behavioral Health, Outpatient

$65 Copay Deductible NA

$60 Copay Deductible NA

$75 Copay Deductible NA 0% 0% 0%

Mental/Behavioral Health, Inpatient 20% 20% 40% 0% 0% 0%

Prescription Drugs G=Generic B=Brand N=Non-formulary S=Specialty

Deductible NA

$15 G $70 B 40% N 20% S

Deductible NA

$15 G $70 B 40% N 20% S

Deductible NA

$15 G $70 B

$150 N $200 S

After deductible

0%

After deductible

0%

After deductible

0%

4

2020 Small Group Point of Service Plans

Endnotes on last page.

Covered Services

Platinum 500

w/Copay Platinum 1000

w/Copay Gold

1000/80 w/Copay Gold 1500/80 Gold 2500/70 w/Copay

(Calendar Year Benefits) In Network

Out-of-Network

In Network

Out-of-Network

In Network

Out-of-Network

In Network

Out-of-Network

In Network

Out-of-Network

Annual Deductible Individual/Family†

$500/ $1,000

$1,000/ $2,000

$1,000/ $2,000

$2,000/ $4,000

$1,000/ $2,000

$2,000/ $4,000

$1,500/ $3,000

$3,000/ $6,000

$2,500/ $5,000

$5,000/ $10,000

Annual Out-of-Pocket Maximum Individual/Family†

$1,500/ $3,000

$3,000/ $6,000

$3,000/ $6,000

$6,000/ $12,000

$4,500/ $9,000

$9,000/ $18,000

$4,000/ $8,000

$8,000/ $16,000

$5,500/ $11,000

$11,000/ $22,000

Preventive Care* 100% Coverage

Not covered

100% Coverage

Not covered

100% Coverage

Not covered

100% Coverage

Not covered

100% Coverage

Not covered

Deductible applies unless otherwise noted (Copays do not apply to deductible)

Office Visits Primary/Specialist

$25/$50 Copay

Deductible NA

40%

$20/$40 Copay

Deductible NA

40%

$40/$90 Copay

Deductible NA

40% 20% 40%

$45/$90 Copay

Deductible NA

40%

Chiropractic $25

Copay Deductible

NA

40%

$20 Copay

Deductible NA

40%

$40 Copay

Deductible NA

40% 20% 40%

$45 Copay

Deductible NA

40%

Urgent Care** $75

Copay Deductible

NA

$75 Copay

Deductible NA

$75 Copay

Deductible NA

$75 Copay

Deductible NA

$125 Copay

Deductible NA

$125 Copay

Deductible NA

20% 20%

$150 Copay

Deductible NA

$150 Copay

Deductible NA

Emergency Room Services** (Deductible, Copay, then coinsurance)

$150 Copay

then 20%

$150 Copay

then 20%

$175 Copay

then 20%

$175 Copay

then 20%

$250 Copay

then 20%

$250 Copay

then 20%

$250 Copay

then 20%

$250 Copay

then 20%

$300 Copay

then 30%

$300 Copay

then 30%

Ambulance 20% 20% 20% 20% 20% 20% 20% 20% 30% 30% Hospitalization Inpatient/outpatient 20% 40% 20% 40% 20% 40% 20% 40% 30% 40%

Outpatient Lab/Radiology 20% 40% 20% 40% 20% 40% 20% 40% 30% 40%

Durable Medical Equipment 20% 40% 20% 40% 20% 40% 20% 40% 30% 40%

Skilled Nursing Facilities 20% 40% 20% 40% 20% 40% 20% 40% 30% 40%

Home Health Care 20% 40% 20% 40% 20% 40% 20% 40% 30% 40% Rehabilitation PT/OT/ST max of 20 visits each/year

20% 40% 20% 40% 20% 40% 20% 40% 30% 40%

Prenatal/Postnatal Care & Delivery 20% 40% 20% 40% 20% 40% 20% 40% 30% 40%

Mental/Behavioral Health, Outpatient

$25 Copay

Deductible NA

40%

$20 Copay

Deductible NA

40%

$40 Copay

Deductible NA

40% 20% 40%

$45 Copay

Deductible NA

40%

Mental/Behavioral Health, Inpatient 20% 40% 20% 40% 20% 40% 20% 40% 30% 40%

Prescription Drugs

G=Generic B=Brand N=Non-formulary S=Specialty

Deductible NA

$5 G $30 B $60 N $120 S

Not

covered

Deductible NA

$5 G $30 B $60 N $120 S

Not

covered

Deductible NA

$10 G $50 B 40% N 20% S

Not

covered

Deductible NA

$10 G $50 B 40% N 20% S

Not

covered

Deductible NA

$10 G $50 B 40% N 20% S

Not

covered

5

2020 Small Group Point of Service Plans

Endnotes on last page.

Covered Services

Silver 2000/70 w/Copay

Silver 2000/70

Silver 3000/80 w/Copay

Silver 5000/80 w/Copay

Bronze 7750/60

w/Copay*** (Calendar Year

Benefits) In

Network Out-of-Network

In Network

Out-of-Network

In Network

Out-of- Network

In Network

Out-of-Network

In Network

Out-of-Network

Annual Deductible Individual/Family†

$2,000/ $4,000

$4,000/ $8,000

$2,000/ $4,000

$4,000/ $8,000

$3,000/ $6,000

$6,000/ $12,000

$5,000/ $10,000

$10,000/ $20,000

$7,750/ $15,500

$15,500/ $31,000

Annual Out-of-Pocket Maximum Individual/Family†

$8,150/ $16,300

$16,300/ $32,600

$8,150/ $16,300

$16,300/ $32,600

$8,150/ $16,300

$16,300/ $32,600

$8,150/ $16,300

$16,300/ $32,600

$8,150/ $16,300

$16,300/ $32,600

Preventive Care* 100% Coverage

Not covered

100% Coverage

Not Covered

100% Coverage

Not Covered

100% Coverage

Not covered

100% Coverage

Not covered

Deductible applies unless otherwise noted (Copays do not apply to deductible)

Office Visits Primary/Specialist

$70/$150 Copay

Deductible NA

40% 30% 40%

$65/$150 Copay

Deductible NA

40%

$60/$150 Copay

Deductible NA

40%

$75/$150 Copay

Deductible NA

50%

Chiropractic $70

Copay Deductible

NA

40% 30% 40%

$65 Copay

Deductible NA

40%

$60 Copay

Deductible NA

40%

$75 Copay

Deductible NA

50%

Urgent Care** $200

Copay Deductible

NA

$200 Copay

Deductible NA

30% 30% $200

Copay Deductible

NA

$200 Copay

Deductible NA

$200 Copay

Deductible NA

$200 Copay

Deductible NA

40% 40%

Emergency Room Services** (Deductible, Copay, then coinsurance)

$300 Copay

then 30%

$300 Copay

then 30%

$250 Copay

then 30%

$250 Copay

then 30%

$300 Copay

then 20%

$300 Copay

then 20%

$300 Copay

then 20%

$300 Copay

then 20% 40% 40%

Ambulance 30% 30% 30% 30% 20% 20% 20% 20% 40% 40% Hospitalization Inpatient/outpatient 30% 40% 30% 40% 20% 40% 20% 40% 40% 50%

Outpatient Lab/Radiology 30% 40% 30% 40% 20% 40% 20% 40% 40% 50%

Durable Medical Equipment 30% 40% 30% 40% 20% 40% 20% 40% 40% 50%

Skilled Nursing Facilities 30% 40% 30% 40% 20% 40% 20% 40% 40% 50%

Home Health Care 30% 40% 30% 40% 20% 40% 20% 40% 40% 50% Rehabilitation PT/OT/ST max of 20 visits each/year

30% 40% 30% 40% 20% 40% 20% 40% 40% 50%

Prenatal/Postnatal Care & Delivery 30% 40% 30% 40% 20% 40% 20% 40% 40% 50%

Mental/Behavioral Health, Outpatient

$70 Copay

Deductible NA

40% 30% 40%

$65 Copay

Deductible NA

40%

$60 Copay

Deductible NA

40%

$75 Copay

Deductible NA

50%

Mental/Behavioral Health, Inpatient 30% 40% 30% 40% 20% 40% 20% 40% 40% 50%

Prescription Drugs

G=Generic B=Brand N=Non-formulary S=Specialty

Deductible NA

$15 G $70 B 40% N 40% S

Not

covered

Deductible NA

$15 G $70 B 40% N 20% S

Not

covered

Deductible NA

$15 G $70 B 40% N 20% S

Not

covered

Deductible NA

$15 G $70 B 40% N 20% S

Not

covered

Deductible NA

$15 G $70 B

$150 N $200 S

Not

covered

6

2020 Small Group Point of Service Plans

Plans in blue are qualified high-deductible plans compatible with Health Savings Accounts.

Endnotes on last page

Covered Services Gold HDHP 100 Silver HDHP 100 Bronze HDHP 100

(Calendar Year Benefits) In Network

Out-of-Network

In Network

Out-of-Network

In Network

Out-of-Network

Annual Deductible Individual/Family†

$3,000/ $6,000

$6,000/ $12,000

$5,500/ $11,000

$11,000/ $22,000

$6,900/ $13,800

$13,800/ $27,600

Annual Out-of-Pocket Maximum Individual/Family†

$3,000/ $6,000

$6,000/ $12,300

$5,500/ $11,000

$11,000/ $22,000

$6,900/ $13,800

$13,800/ $27,600

Preventive Care* 100% Coverage

Not Covered

100% Coverage Not Covered 100%

Coverage Not Covered

In addition to meeting the deductible, member pays

Office Visits Primary/Specialist 0% 0% 0% 0% 0% 0%

Chiropractic 0% 0% 0% 0% 0% 0%

Urgent Care** 0% 0% 0% 0% 0% 0%

Emergency Room Services** (Deductible, Copay, then coinsurance)

0% 0% 0% 0% 0% 0%

Ambulance 0% 0% 0% 0% 0% 0% Hospitalization Inpatient/outpatient 0% 0% 0% 0% 0% 0%

Outpatient Lab/Radiology 0% 0% 0% 0% 0% 0% Durable Medical Equipment 0% 0% 0% 0% 0% 0%

Skilled Nursing Facilities 0% 0% 0% 0% 0% 0%

Home Health Care 0% 0% 0% 0% 0% 0% Rehabilitation PT/OT/ST max of 20 visits each/year

0% 0% 0% 0% 0% 0%

Prenatal/Postnatal Care & Delivery 0% 0% 0% 0% 0% 0%

Mental/Behavioral Health, Outpatient 0% 0% 0% 0% 0% 0%

Mental/Behavioral Health, Inpatient 0% 0% 0% 0% 0% 0%

Prescription Drugs

G=Generic B=Brand N=Non-formulary S=Specialty

After deductible

0%

Not covered

After deductible

0%

Not covered

After deductible

0%

Not covered

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Endnotes: † Once a member of a family plan meets the

individual deductible or maximum out-of-pocket, Health Tradition begins paying for covered services for that person, regardless of whether the family deductible or out-of-pocket maximum has been met.

* This Benefit Plan provides 100% coverage in-

network for preventive health services as defined in Section 1001 of the Patient Protection and Affordable Care Act, with no cost sharing. Routine vision and hearing exam included.

** We cover the following out-of-network services

as in-network: emergency care, certain urgent care, and services for which we have prior authorized a referral. In the service area, HMO plan does not cover out-of-network urgent care. See Certificate of Coverage for plan details.

*** Bronze 7750 is not considered a qualified HDHP

plan because it exceeds the maximum out of pocket set by the IRS.

45 Nob Hill Rd Madison, WI 53713 HealthTradition.com 1.877.832.1823

Please see plan documents here:

https://www.healthtradition.com/smallgroup

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