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Public Employees Insurance Program (PEIP)

Introduction and Summary of Benefit for PEIP – 2024 renewal

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1/1/24 RENEWALS

The renewal rates for January 2024 will be based on a combination of the group’s claims and the overall pool. Group’s credibility is based on enrollment size.

PEIP will be offering the Blue Cross and HealthPartners network choices for 2024 (PreferredOne is no longer available). If you are currently participating with Preferred One you MUST complete a new enrollment form to be effective 1.1.24.

The 2024 clinic directory will be available approximately 10.15.23 at www.innovomn.com. Please check to see if your clinic cost level has changed.

Innovo Benefits Administration is easy to access on our PEIP Online Enrollment Portal. Access the Online Enrollment Portal by visiting – https://www.mnpeip.com. Please consult with your HR Office prior to submitting changes online.

No member action is required unless you are changing networks (BC/HP) or changing plan designs (High/Value/HSA). If you are changing clinics only, please call the customer service number on your ID card.

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Plan Changes for 2024

There are a few plan revisions for 2024

Enhanced coverage of infertility for Blue Cross members (similar to HealthPartners coverage)
$0 or reduced office copays for mental health treatment (deductible applies only on the HSA plan).
The HSA plan deductible increased due to IRS rules.
The out of area benefits for members living out of state has been revised also.

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Public Employees Insurance Program (PEIP) & Innovo

The Public Employee Insurance Program (PEIP) is a state of Minnesota health plan available to cities, counties and school districts. PEIP is able to leverage off the state employee plan and use the negotiating clout of their size to offer very low administrative costs and multiple network carriers to our member groups.

Deloitte, the world’s largest professional services organization, handles the financials, underwriting, and consulting.

Innovo Benefits is the third party administrator for the PEIP program. Our core staff has worked with the PEIP program since it was created.

Our strength is vast experience and dedication to servicing the PEIP program. Our 30 years of experience has proven to be vital in dealing with the myriad of issues that arise in servicing our employers and members.

The PEIP pool has grown to approximately 300 employer groups covering 35,000 members.

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Overview of PEIP Coverage

Members have the choice of three plan design options and two network carriers

Primary Care Clinic model where clinics are broken down into 4 tiers or cost levels (CL).

Each family member can choose their own primary care clinic (PCC) and your benefit level is based on the cost level of your PCC choice. More efficient, lower cost clinics provide the highest benefit levels.

Generally, all routine and non-emergency care flows through your primary care, referrals are typically required for care outside your PCC.

Prescription drugs are through the CVS Caremark network for both network carriers.

CVS Caremark has a large network of pharmacies throughout the state/country.

You do not have to use a CVS Retail pharmacy.

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Step by Step Instructions will guide

You through the enrollment steps and provide information you need to make election choices.

Step 1 – Choose Your Plan Level

Advantage High is the highest level of benefits and the highest payroll deduction.

Value is a mid-rage option with a little higher deductible and out of pocket expenses but lower payroll deduction.

HSA option has highest deductible and out of pocket expenses and the lowest payroll deduction.

One plan is selected for employee + 1 and family coverage.

You can change your plan level each year during open enrollment.

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Step 2 – Choose Your Health Plan/

Network

HealthPartners

Blue Cross Blue Shield

Network selection does not affect the cost of the plan or your premium rate.

Both networks have the same plan design levels.

One network is selected for employee + 1 and family coverage.

You can change your network each year during open enrollment.

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Step 3 – Choose Your Primary

Care Clinic

Primary Care Clinics (PCC) are placed in four cost levels, based on the care system and overall cost/quality of their delivery of care.

Your final benefit level is based on the on the cost level of the primary clinic you choose related to your Health Plan and Network choice.

You will choose a primary care clinic (PCC) for each family member.

PCC does not need to be the same for each family member, nor the same Cost Level.

PCC can be changed monthly by calling your network carrier customer service number on the back of your ID card.

2024 clinic directory will be available at www.innovomn.com beginning in October.

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Specialists

Referrals to specialists are covered at the same cost level as your PCC.

Members can Self-Refer* to specialists for OBGyn, Mental Health, Chemical Dependency, Chiropractic Care and Routine Vision.

*Practitioners must participate in your network carrier’s self-referral network.

No referrals are needed for Urgent Care or Emergency Services.

CVS Caremark (PBM)

CVS Caremark is the pharmacy benefit manager for PEIP and provides services for all three networks.

has a nationwide network of more than 68,000 participating retail pharmacies.

PEIP includes both CVS and non-CVS pharmacies. Pharmacy locator tool at www.innovomn.com

Convenient access to retail, specialty services and mail order delivery options.

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PEIP Plan Documents and Information

Once enrolled, you will receive two ID cards.

1) One ID card is for medical and will come from your network choice (HP, BC).

2) The second ID card is for all pharmacy services and will come from CVS Caremark.

All PEIP plan documents and tools

are posted on the PEIP website at

www.innovomn.com.

The website includes Plan Summaries and

Plan Documents, Statewide Clinic Directory, Summary Benefit Comparisons (SBC’s), Pharmacy Tools and informative Q&A.

PEIP Customer Service is available from:

7:30am to 4:30pm

952-746-3101

800-829-5601

Or eMail your question to

service@innovomn.com

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High Plan

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Advantage High plan

Highest benefit level

(Highest payroll deduction)

Preventive Routine Care

covered at 100%

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 Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams	Nothing	Nothing	Nothing	Nothing
B. Annual First Dollar Deductible * (single/family)	$250 / 500	$400 / 800	$750 / 1,500	$1,500 / 3,000
C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care Outpatient visits in a physician’s office Chiropractic services Urgent Care clinic visits (in & out of network)	$30 copay per visit annual deductible applies	$35 copay per visit annual deductible applies	$65 copay per visit annual deductible applies	$85 copay per visit annual deductible applies
Outpatient office visits for mental health and chemical dependency	$0 copay per visit not subject to deductible	$0 copay per visit not subject to deductible	$50 copay per visit annual deductible applies	$70 copay per visit annual deductible applies
D. Network Convenience Clinics & Online Care	Nothing	Nothing	Nothing	Nothing
E. Emergency Care (in or out of network) Emergency care received in a hospital emergency room	$100 copay not subject to deductible	$125 copay not subject to deductible	$150 copay not subject to deductible	$350 copay not subject to deductible
F. Inpatient Hospital Copay	$100 copay annual deductible applies	$200 copay annual deductible applies	$500 copay annual deductible applies	25% coinsurance annual deductible applies
G. Outpatient Surgery Copay	$60 copay annual deductible applies	$120 copay annual deductible applies	$250 copay annual deductible applies	25% coinsurance annual deductible applies
H. Hospice and Skilled Nursing Facility	Nothing	Nothing	Nothing	Nothing
I. Prosthetics and Durable Medical Equipment	20% coinsurance	20% coinsurance	20% coinsurance	25% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	10% coinsurance annual deductible applies	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan High Option 2024 - 2025 Benefits Schedule

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Advantage High plan

Prescription Drugs

No Deductible

Copay per 30 day supply

Typically tiers are broken out …

Tier 1 – $18, generic & common name brand

Tier 2 – $30, name brand, some generic & specialty

Tier 3 – $55, typically specialty medications

(If medications are less than the copay, only pay the price of medication.)

Formulary tools for pricing covered meds at www.innovomn.com

RX Out of Pocket Max - $1,050/$2,100

Mail Order for 90 day medications for 2 copays

(also available at retail CVS pharmacies)

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan High Option 2024 - 2025 Benefits Schedule

Benefit Provision	Cost Level 1 – You Pay	Cost Level 2 – You Pay	Cost Level 3 – You Pay	Cost Level 4 – You Pay
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	10% coinsurance annual deductible applies	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance 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) Radiation/chemotherapy Dialysis Day treatment for mental health and chemical dependency Other diagnostic or treatment related outpatient services	5% coinsurance annual deductible applies	5% coinsurance annual deductible applies	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies
M. Prescription Drugs 30-day supply of Tier 1, Tier 2, or Tier 3 prescription drugs, including insulin; or a 3-cycle supply of oral contraceptives.	$18 tier one $30 tier two $55 tier three	$18 tier one $30 tier two $55 tier three	$18 tier one $30 tier two $55 tier three	$18 tier one $30 tier two $55 tier three
N. Plan Maximum Out-of-Pocket Expense for Prescription Drugs (single/family)	$1,050 / 2,100	$1,050 / 2,100	$1,050 / 2,100	$1,050 / 2,100
O. Plan Maximum Out-of-Pocket Expense (excluding prescription drugs) (single/family)	$1,700 / 3,400	$1,700 / 3,400	$2,400 / 4,800	$3,600 / 7,200

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Advantage High plan

Your Deductible is based on your cost level.

CL 1 - $250/$500

CL2 – $400/$800

(Higher cost clinics, CL3 and CL4, will have higher deductibles.)

CL3 - $750/$1,500

CL4 - $1,500/$3,000

Medical Deductible is paid in full by the member first, then member is only responsible for copayments or coinsurance.

Deductibles are embedded.

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 Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams	Nothing	Nothing	Nothing	Nothing
B. Annual First Dollar Deductible * (single/family)	$250 / 500	$400 / 800	$750 / 1,500	$1,500 / 3,000
C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care Outpatient visits in a physician’s office Chiropractic services Urgent Care clinic visits (in & out of network)	$30 copay per visit annual deductible applies	$35 copay per visit annual deductible applies	$65 copay per visit annual deductible applies	$85 copay per visit annual deductible applies
Outpatient office visits for mental health and chemical dependency	$0 copay per visit not subject to deductible	$0 copay per visit not subject to deductible	$50 copay per visit annual deductible applies	$70 copay per visit annual deductible applies
D. Network Convenience Clinics & Online Care	Nothing	Nothing	Nothing	Nothing
E. Emergency Care (in or out of network) Emergency care received in a hospital emergency room	$100 copay not subject to deductible	$125 copay not subject to deductible	$150 copay not subject to deductible	$350 copay not subject to deductible
F. Inpatient Hospital Copay	$100 copay annual deductible applies	$200 copay annual deductible applies	$500 copay annual deductible applies	25% coinsurance annual deductible applies
G. Outpatient Surgery Copay	$60 copay annual deductible applies	$120 copay annual deductible applies	$250 copay annual deductible applies	25% coinsurance annual deductible applies
H. Hospice and Skilled Nursing Facility	Nothing	Nothing	Nothing	Nothing
I. Prosthetics and Durable Medical Equipment	20% coinsurance	20% coinsurance	20% coinsurance	25% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	10% coinsurance annual deductible applies	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan High Option 2024 - 2025 Benefits Schedule

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Advantage High plan

After the deductible has been satisfied, member only pays copayments or coinsurance for services.

Copayment is a flat dollar amount for visit or service.

Coinsurance is a % amount of the bill.

Prosthetics and Durable Medical bypass the deductible with member paying only 20% copay (25% with CL4).

Network Convenience Clinics & Online Care, Hospice – no deductible, no copay

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 Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams	Nothing	Nothing	Nothing	Nothing
B. Annual First Dollar Deductible * (single/family)	$250 / 500	$400 / 800	$750 / 1,500	$1,500 / 3,000
C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care Outpatient visits in a physician’s office Chiropractic services Urgent Care clinic visits (in & out of network)	$30 copay per visit annual deductible applies	$35 copay per visit annual deductible applies	$65 copay per visit annual deductible applies	$85 copay per visit annual deductible applies
Outpatient office visits for mental health and chemical dependency	$0 copay per visit not subject to deductible	$0 copay per visit not subject to deductible	$50 copay per visit annual deductible applies	$70 copay per visit annual deductible applies
D. Network Convenience Clinics & Online Care	Nothing	Nothing	Nothing	Nothing
E. Emergency Care (in or out of network) Emergency care received in a hospital emergency room	$100 copay not subject to deductible	$125 copay not subject to deductible	$150 copay not subject to deductible	$350 copay not subject to deductible
F. Inpatient Hospital Copay	$100 copay annual deductible applies	$200 copay annual deductible applies	$500 copay annual deductible applies	25% coinsurance annual deductible applies
G. Outpatient Surgery Copay	$60 copay annual deductible applies	$120 copay annual deductible applies	$250 copay annual deductible applies	25% coinsurance annual deductible applies
H. Hospice and Skilled Nursing Facility	Nothing	Nothing	Nothing	Nothing
I. Prosthetics and Durable Medical Equipment	20% coinsurance	20% coinsurance	20% coinsurance	25% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	10% coinsurance annual deductible applies	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan High Option 2024 - 2025 Benefits Schedule

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Advantage High plan

Medical Out of Pocket Maximum

Once the deductible, copays and coinsurance expenses for medical total a certain level, the plan covers 100% of eligible medical expenses for the remaining contract year.

Your Medical OOP Max is based on your cost level.

CL1 - $1,700/$3,400

CL2 - $1,700/$3,400

(Higher cost clinics, CL3 and CL4, will have higher OOP max.)

CL3 - $2,400/$4,800

CL4 - $3,600/$7,200

OOP Max is embedded.

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan High Option 2024 - 2025 Benefits Schedule

Benefit Provision	Cost Level 1 – You Pay	Cost Level 2 – You Pay	Cost Level 3 – You Pay	Cost Level 4 – You Pay
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	10% coinsurance annual deductible applies	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance 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) Radiation/chemotherapy Dialysis Day treatment for mental health and chemical dependency Other diagnostic or treatment related outpatient services	5% coinsurance annual deductible applies	5% coinsurance annual deductible applies	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies
M. Prescription Drugs 30-day supply of Tier 1, Tier 2, or Tier 3 prescription drugs, including insulin; or a 3-cycle supply of oral contraceptives.	$18 tier one $30 tier two $55 tier three	$18 tier one $30 tier two $55 tier three	$18 tier one $30 tier two $55 tier three	$18 tier one $30 tier two $55 tier three
N. Plan Maximum Out-of-Pocket Expense for Prescription Drugs (single/family)	$1,050 / 2,100	$1,050 / 2,100	$1,050 / 2,100	$1,050 / 2,100
O. Plan Maximum Out-of-Pocket Expense (excluding prescription drugs) (single/family)	$1,700 / 3,400	$1,700 / 3,400	$2,400 / 4,800	$3,600 / 7,200

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Value Plan

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Value Plan

Mid-range benefit level

Preventive Routine Care

covered at 100%

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 Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams	Nothing	Nothing	Nothing	Nothing
B. Annual First Dollar Deductible * (single/family)	$600 / 1,200	$850 / 1,700	$1,300 / 2,600	$2,100 / 4,200
C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care Outpatient visits in a physician’s office Chiropractic services Urgent Care clinic visits (in or out of network)	$35 copay per visit annual deductible applies	$40 copay per visit annual deductible applies	$100 copay per visit annual deductible applies	$125 copay per visit annual deductible applies
Outpatient office visits for mental health and chemical dependency	$0 copay per visit not subject to deductible	$0 copay per visit not subject to deductible	$80 copay per visit annual deductible applies	$105 copay per visit annual deductible applies
D. Network Convenience Clinics and Online Care	Nothing	Nothing	Nothing	Nothing
E. Emergency Care (in or out of network) Emergency care received in a hospital emergency room	$225 copay not subject to deductible	$250 copay not subject to deductible	$275 copay not subject to deductible	$500 copay not subject to deductible
F. Inpatient Hospital Copay	$150 copay annual deductible applies	$325 copay annual deductible applies	$750 copay annual deductible applies	30% coinsurance annual deductible applies
G. Outpatient Surgery Copay	$100 copay annual deductible applies	$175 copay annual deductible applies	$350 copay annual deductible applies	35% coinsurance annual deductible applies
H. Hospice and Skilled Nursing Facility	Nothing	Nothing	Nothing	Nothing
I. Prosthetics and Durable Medical Equipment	20% coinsurance	20% coinsurance	25% coinsurance	35% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance annual deductible applies

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan Value Option 2024 - 2025 Benefits Schedule

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Value Plan

Prescription Drugs

No Deductible

Copay per 30 day supply

Typically tiers are broken out …

Tier 1 – $25, generic & common name brand

Tier 2 – $45, name brand, some generic & specialty

Tier 3 – $70, typically specialty medications

(If medications are less than the copay, only pay the price of medication.)

Formulary tools for pricing covered meds at

www.innovomn.com

RX Out of Pocket Max - $1,250/$2,500

Mail Order for 90 day medications for 2 copays

(also available at retail CVS pharmacies)

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan Value Option 2024 - 2025 Benefits Schedule

Benefit Provision	Cost Level 1 – You Pay	Cost Level 2 – You Pay	Cost Level 3 – You Pay	Cost Level 4 – You Pay
I. Prosthetics and Durable Medical Equipment	20% coinsurance	20% coinsurance	25% coinsurance	35% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance 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) Radiation/chemotherapy Dialysis Day treatment for mental health and chemical dependency Other diagnostic or treatment related outpatient services	10% coinsurance annual deductible applies	10% coinsurance annual deductible applies	20% coinsurance annual deductible applies	35% coinsurance annual deductible applies
M. Prescription Drugs 30-day supply of Tier 1, Tier 2, or Tier 3 prescription drugs, including insulin; or a 3-cycle supply of oral contraceptives.	$25 tier one $45 tier two $70 tier three	$25 tier one $45 tier two $70 tier three	$25 tier one $45 tier two $70 tier three	$25 tier one $45 tier two $70 tier three
N. Plan Maximum Out-of-Pocket Expense for Prescription Drugs (single/family)	$1,250 / 2,500	$1,250 / 2,500	$1,250 / 2,500	$1,250 / 2,500
O. Plan Maximum Out-of-Pocket Expense (excluding prescription drugs) (single/family)	$2,600 / 5,200	$2,600 / 5,200	$3,800 / 7,600	$4,800 / 9,600

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Value Plan

Your Deductible is based on your cost level.

CL 1 - $600/$1,200

CL2 – $850/$1,700

(Higher cost clinics, CL3 and CL4, will have higher deductibles.)

CL3 - $1,300/$2,600

CL4 - $2,100/$4,200

Medical Deductible is paid in full by the member first, then member is only responsible for copayments or coinsurance.

Deductibles are embedded.

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan Value Option 2024 - 2025 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 Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams	Nothing	Nothing	Nothing	Nothing
B. Annual First Dollar Deductible * (single/family)	$600 / 1,200	$850 / 1,700	$1,300 / 2,600	$2,100 / 4,200
C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care Outpatient visits in a physician’s office Chiropractic services Urgent Care clinic visits (in or out of network)	$35 copay per visit annual deductible applies	$40 copay per visit annual deductible applies	$100 copay per visit annual deductible applies	$125 copay per visit annual deductible applies
Outpatient office visits for mental health and chemical dependency	$0 copay per visit not subject to deductible	$0 copay per visit not subject to deductible	$80 copay per visit annual deductible applies	$105 copay per visit annual deductible applies
D. Network Convenience Clinics and Online Care	Nothing	Nothing	Nothing	Nothing
E. Emergency Care (in or out of network) Emergency care received in a hospital emergency room	$225 copay not subject to deductible	$250 copay not subject to deductible	$275 copay not subject to deductible	$500 copay not subject to deductible
F. Inpatient Hospital Copay	$150 copay annual deductible applies	$325 copay annual deductible applies	$750 copay annual deductible applies	30% coinsurance annual deductible applies
G. Outpatient Surgery Copay	$100 copay annual deductible applies	$175 copay annual deductible applies	$350 copay annual deductible applies	35% coinsurance annual deductible applies
H. Hospice and Skilled Nursing Facility	Nothing	Nothing	Nothing	Nothing
I. Prosthetics and Durable Medical Equipment	20% coinsurance	20% coinsurance	25% coinsurance	35% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance annual deductible applies

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Value Plan

After the deductible has been satisfied, member only pays copayments or coinsurance for services.

Copayment is a flat dollar amount for visit or service.

Coinsurance is a % amount of the bill.

Prosthetics and Durable Medical bypass the deductible with member paying only 20% copay CL1, CL2. (25% CL3, 35% CL4).

Network Convenience Clinics & Online Care, Hospice – no deductible, no copay

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan Value Option 2024 - 2025 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 Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams	Nothing	Nothing	Nothing	Nothing
B. Annual First Dollar Deductible * (single/family)	$600 / 1,200	$850 / 1,700	$1,300 / 2,600	$2,100 / 4,200
C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care Outpatient visits in a physician’s office Chiropractic services Urgent Care clinic visits (in or out of network)	$35 copay per visit annual deductible applies	$40 copay per visit annual deductible applies	$100 copay per visit annual deductible applies	$125 copay per visit annual deductible applies
Outpatient office visits for mental health and chemical dependency	$0 copay per visit not subject to deductible	$0 copay per visit not subject to deductible	$80 copay per visit annual deductible applies	$105 copay per visit annual deductible applies
D. Network Convenience Clinics and Online Care	Nothing	Nothing	Nothing	Nothing
E. Emergency Care (in or out of network) Emergency care received in a hospital emergency room	$225 copay not subject to deductible	$250 copay not subject to deductible	$275 copay not subject to deductible	$500 copay not subject to deductible
F. Inpatient Hospital Copay	$150 copay annual deductible applies	$325 copay annual deductible applies	$750 copay annual deductible applies	30% coinsurance annual deductible applies
G. Outpatient Surgery Copay	$100 copay annual deductible applies	$175 copay annual deductible applies	$350 copay annual deductible applies	35% coinsurance annual deductible applies
H. Hospice and Skilled Nursing Facility	Nothing	Nothing	Nothing	Nothing
I. Prosthetics and Durable Medical Equipment	20% coinsurance	20% coinsurance	25% coinsurance	35% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance annual deductible applies

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Value Plan

Medical Out of Pocket Maximum

Once the deductible, copays and coinsurance expenses for medical total a certain level, the plan covers 100% of eligible medical expenses for the remaining contract year.

Your Medical OOP Max is based on your cost level.

CL1 - $2,600/$5,200

CL2 - $2,600/$5,200

(Higher cost clinics, CL3 and CL4, will have higher OOP max.)

CL3 - $3,800/$7,600

CL4 - $4,800/$9,600

OOP Max is embedded.

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan Value Option 2024 - 2025 Benefits Schedule

Benefit Provision	Cost Level 1 – You Pay	Cost Level 2 – You Pay	Cost Level 3 – You Pay	Cost Level 4 – You Pay
I. Prosthetics and Durable Medical Equipment	20% coinsurance	20% coinsurance	25% coinsurance	35% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance annual deductible applies
K. MRI/CT Scans	10% coinsurance annual deductible applies	15% coinsurance annual deductible applies	25% coinsurance annual deductible applies	35% coinsurance 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) Radiation/chemotherapy Dialysis Day treatment for mental health and chemical dependency Other diagnostic or treatment related outpatient services	10% coinsurance annual deductible applies	10% coinsurance annual deductible applies	20% coinsurance annual deductible applies	35% coinsurance annual deductible applies
M. Prescription Drugs 30-day supply of Tier 1, Tier 2, or Tier 3 prescription drugs, including insulin; or a 3-cycle supply of oral contraceptives.	$25 tier one $45 tier two $70 tier three	$25 tier one $45 tier two $70 tier three	$25 tier one $45 tier two $70 tier three	$25 tier one $45 tier two $70 tier three
N. Plan Maximum Out-of-Pocket Expense for Prescription Drugs (single/family)	$1,250 / 2,500	$1,250 / 2,500	$1,250 / 2,500	$1,250 / 2,500
O. Plan Maximum Out-of-Pocket Expense (excluding prescription drugs) (single/family)	$2,600 / 5,200	$2,600 / 5,200	$3,800 / 7,600	$4,800 / 9,600

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HSA Plan

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HSA Plan

High deductible, lowest payroll deduction

HSA plan meets IRS rules for QHDHP and works differently than High & Value plan:

Medical and Prescription Drugs are combined
Deductible must be satisfied before member moves into copayments or coinsurance

Preventive Routine Care

covered at 100%

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 Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams	Nothing	Nothing	Nothing	Nothing
B. Annual First Dollar Deductible * Combined Medical/Pharmacy (single coverage) Combined Medical/Pharmacy (family coverage)	$1,600	$2,000	$3,000	$4,000
	$3,200 per family member $3,400 per family	$3,200 per family member $4,000 per family	$4,800 per family member $6,000 per family	$6,400 per family member $8,000 per family
C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care Outpatient visits in a physician’s office Chiropractic services Urgent Care clinic visits (in & out of network)	$45 copay per visit annual deductible applies	$55 copay per visit annual deductible applies	$105 copay per visit annual deductible applies	$130 copay per visit annual deductible applies
Outpatient office visits for mental health and chemical dependency	$0 copay per visit annual deductible applies	$0 copay per visit annual deductible applies	$85 copay per visit annual deductible applies	$110 copay per visit annual deductible applies
D. Network Convenience Clinics & Online Care	$0 copay annual deductible applies	$0 copay annual deductible applies	$0 copay annual deductible applies	$0 copay annual deductible applies
E. Emergency Care (in or out of network) Emergency care received in a hospital emergency room	$250 copay annual deductible applies	$300 copay annual deductible applies	$350 copay annual deductible applies	$600 copay annual deductible applies
F. Inpatient Hospital Copay	$400 copay annual deductible applies	$650 copay annual deductible applies	$1,500 copay annual deductible applies	50% coinsurance annual deductible applies
G. Outpatient Surgery Copay	$250 copay annual deductible applies	$400 copay annual deductible applies	$800 copay annual deductible applies	50% coinsurance annual deductible applies
H. Hospice and Skilled Nursing Facility	Nothing after annual deductible	Nothing after annual deductible	Nothing after annual deductible	Nothing after annual deductible
I. Prosthetics and Durable Medical Equipment	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies
K. MRI/CT Scans	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan HSA-Compatible 2024 - 2025 Benefits Schedule

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HSA Plan

Prescription Drugs

After Deductible, Copay per 30 day supply

Typically tiers are broken out …

Tier 1 – $30, generic & common name brand

Tier 2 – $50, name brand, some generic & specialty

Tier 3 – $75, typically specialty medications

(If medications are less than the copay, only pay the price of medication.)

Formulary tools for pricing covered meds at

www.innovomn.com

Mail Order for 90 day medications for 2 copays, after deductible is met (Also available at retail CVS pharmacies)

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan HSA-Compatible 2024 - 2025 Benefits Schedule

Benefit Provision	Cost Level 1 – You Pay	Cost Level 2 – You Pay	Cost Level 3 – You Pay	Cost Level 4 – You Pay
K. MRI/CT Scans	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance 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) Radiation/chemotherapy Dialysis Day treatment for mental health and chemical dependency Other diagnostic or treatment related outpatient services	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies
M. Prescription Drugs 30-day supply of Tier 1, Tier 2, or Tier 3 prescription drugs, including insulin; or a 3-cycle supply of oral contraceptives.	$30 tier one $50 tier two $75 tier three annual deductible applies	$30 tier one $50 tier two $75 tier three annual deductible applies	$30 tier one $50 tier two $75 tier three annual deductible applies	$30 tier one $50 tier two $75 tier three annual deductible applies
N. Plan Maximum Out-of-Pocket Expense** (including prescription drugs) Single Coverage Family Coverage	$3,000	$3,000	$4,000	$5,000
	$5,000 per family member $6,000 per family	$5,000 per family member $6,000 per family	$6,900 per family member $8,000 per family	$6,900 per family member $10,000 per family

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HSA Plan

Your Deductible is based on your cost level.

CL 1 - $1,500/$3,000

CL2 – $2,000/$4,000

(Higher cost clinics, CL3 and CL4, will have higher deductibles.)

CL3 - $3,000/$6,000

CL4 - $4,000/$8,000

Note: Family Coverage has an embedded individual deductible.

Deductible is paid in full by the member first for medical and prescription drugs, then member is only responsible for copayments or coinsurance.

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 Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams	Nothing	Nothing	Nothing	Nothing
B. Annual First Dollar Deductible * Combined Medical/Pharmacy (single coverage) Combined Medical/Pharmacy (family coverage)	$1,600	$2,000	$3,000	$4,000
	$3,200 per family member $3,400 per family	$3,200 per family member $4,000 per family	$4,800 per family member $6,000 per family	$6,400 per family member $8,000 per family
C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care Outpatient visits in a physician’s office Chiropractic services Urgent Care clinic visits (in & out of network)	$45 copay per visit annual deductible applies	$55 copay per visit annual deductible applies	$105 copay per visit annual deductible applies	$130 copay per visit annual deductible applies
Outpatient office visits for mental health and chemical dependency	$0 copay per visit annual deductible applies	$0 copay per visit annual deductible applies	$85 copay per visit annual deductible applies	$110 copay per visit annual deductible applies
D. Network Convenience Clinics & Online Care	$0 copay annual deductible applies	$0 copay annual deductible applies	$0 copay annual deductible applies	$0 copay annual deductible applies
E. Emergency Care (in or out of network) Emergency care received in a hospital emergency room	$250 copay annual deductible applies	$300 copay annual deductible applies	$350 copay annual deductible applies	$600 copay annual deductible applies
F. Inpatient Hospital Copay	$400 copay annual deductible applies	$650 copay annual deductible applies	$1,500 copay annual deductible applies	50% coinsurance annual deductible applies
G. Outpatient Surgery Copay	$250 copay annual deductible applies	$400 copay annual deductible applies	$800 copay annual deductible applies	50% coinsurance annual deductible applies
H. Hospice and Skilled Nursing Facility	Nothing after annual deductible	Nothing after annual deductible	Nothing after annual deductible	Nothing after annual deductible
I. Prosthetics and Durable Medical Equipment	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies
K. MRI/CT Scans	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan HSA-Compatible 2024 - 2025 Benefits Schedule

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HSA Plan

After the deductible has been satisfied, member only pays copayments or coinsurance for services.

Copayment is a flat dollar amount for visit or service.

Coinsurance is a % amount of the bill.

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 Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams	Nothing	Nothing	Nothing	Nothing
B. Annual First Dollar Deductible * Combined Medical/Pharmacy (single coverage) Combined Medical/Pharmacy (family coverage)	$1,600	$2,000	$3,000	$4,000
	$3,200 per family member $3,400 per family	$3,200 per family member $4,000 per family	$4,800 per family member $6,000 per family	$6,400 per family member $8,000 per family
C. Office visits for Illness/Injury, for Outpatient Physical, Occupational or Speech Therapy, and Urgent Care Outpatient visits in a physician’s office Chiropractic services Urgent Care clinic visits (in & out of network)	$45 copay per visit annual deductible applies	$55 copay per visit annual deductible applies	$105 copay per visit annual deductible applies	$130 copay per visit annual deductible applies
Outpatient office visits for mental health and chemical dependency	$0 copay per visit annual deductible applies	$0 copay per visit annual deductible applies	$85 copay per visit annual deductible applies	$110 copay per visit annual deductible applies
D. Network Convenience Clinics & Online Care	$0 copay annual deductible applies	$0 copay annual deductible applies	$0 copay annual deductible applies	$0 copay annual deductible applies
E. Emergency Care (in or out of network) Emergency care received in a hospital emergency room	$250 copay annual deductible applies	$300 copay annual deductible applies	$350 copay annual deductible applies	$600 copay annual deductible applies
F. Inpatient Hospital Copay	$400 copay annual deductible applies	$650 copay annual deductible applies	$1,500 copay annual deductible applies	50% coinsurance annual deductible applies
G. Outpatient Surgery Copay	$250 copay annual deductible applies	$400 copay annual deductible applies	$800 copay annual deductible applies	50% coinsurance annual deductible applies
H. Hospice and Skilled Nursing Facility	Nothing after annual deductible	Nothing after annual deductible	Nothing after annual deductible	Nothing after annual deductible
I. Prosthetics and Durable Medical Equipment	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies
J. Lab (including allergy shots), Pathology, and X-ray (not included as part of preventive care and not subject to office visit or facility copayments)	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies
K. MRI/CT Scans	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan HSA-Compatible 2024 - 2025 Benefits Schedule

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HSA Plan

Medical & RX Out of Pocket Maximum Combined

Once the deductible, copays and coinsurance expenses for medical and prescription drugs total a certain level, the plan covers 100% of eligible expenses for the remaining contract year.

Your Medical & RX OOP Max is based on your cost level.

CL1 - $3,000/$6,000

CL2 - $3,000/$6,000

(Higher cost clinics, CL3 and CL4, will have higher OOP max.)

CL3 - $4,000/$8,000

CL4 - $5,000/$10,000

Note: Family Coverage has an embedded individual out of pocket maximum.

Minnesota Public Employees Insurance Program (PEIP)

Advantage Health Plan HSA-Compatible 2024 - 2025 Benefits Schedule

Benefit Provision	Cost Level 1 – You Pay	Cost Level 2 – You Pay	Cost Level 3 – You Pay	Cost Level 4 – You Pay
K. MRI/CT Scans	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance 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) Radiation/chemotherapy Dialysis Day treatment for mental health and chemical dependency Other diagnostic or treatment related outpatient services	20% coinsurance annual deductible applies	25% coinsurance annual deductible applies	30% coinsurance annual deductible applies	50% coinsurance annual deductible applies
M. Prescription Drugs 30-day supply of Tier 1, Tier 2, or Tier 3 prescription drugs, including insulin; or a 3-cycle supply of oral contraceptives.	$30 tier one $50 tier two $75 tier three annual deductible applies	$30 tier one $50 tier two $75 tier three annual deductible applies	$30 tier one $50 tier two $75 tier three annual deductible applies	$30 tier one $50 tier two $75 tier three annual deductible applies
N. Plan Maximum Out-of-Pocket Expense** (including prescription drugs) Single Coverage Family Coverage	$3,000	$3,000	$4,000	$5,000
	$5,000 per family member $6,000 per family	$5,000 per family member $6,000 per family	$6,900 per family member $8,000 per family	$6,900 per family member $10,000 per family

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Out of Area Coverage�

Out of area benefits

PEIP has revised the out of area benefit plan. Members no longer need to “sign-up” to receive the benefits. Any care out of the service area, MN and bordering counties basically, is covered at cost level 3 for high and value plans, HSA remains the same deductible then 30% coinsurance. Out of area deductibles are separate from in-area PEIP deductibles but do accumulate to out of pocket maximums. Always call the phone number on your ID card to verify benefits. Urgent care and emergency care are still covered at the cost level of your primary clinic.

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Health Enrollment Form

(if your group uses paper forms)

Complete Employee Information Section

Skip. Only complete ‘other health coverage’ section

if you or your dependents will be double covered

while on PEIP.

Choose your health plan network (HP or BC)

Choose your plan level (High, Value, HSA)

Choose your coverage level.

Complete information for all family members. Be

sure to include the name and PCC # for all family

members. (Match PCC # to the health plan

network you choose.)

Sign and date your enrollment form.

1

2

3

4

5

4

5

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Tips

For 2024 both Blue Cross and HealthPartners are available for network selection, they are shown in the far left column as BC or HP

If you are only changing clinics make sure you call the number on your ID card to make that change.

Always check your ID card after open enrollment to make sure the information is correct.

Be sure to note the cost level and correct PCC #

that matches your

Network Carrier

(HP or BC)

when enrolling.

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Questions

PEIP website – www.innovomn.com

For questions regarding PEIP medical coverage,

contact Innovo via phone or email.

952-746-3101 or 800-829-5601

M-F 7:30am – 4:30pm

shawn@innovomn.com

lorrie@innovomn.com

service@innovomn.com

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