This PPO plan includes an HSA in which You can contribute pre-tax dollars to use for eligible medical expenses. Each time you visit the doctor or receive health care services, you can use your pre-tax dollars towards the expenses. The HSA covers incurred expenses by paying them from this allocation until the contribution dollars are exhausted.
| Core Coverage Information | ||
|---|---|---|
| Coverage | In Network | Out Of Network |
| General Services | ||
| Annual Deductible/Individual | $5,000 | $7,500 |
| Annual Deductible/Family | $10,000 | $15,000 |
| Annual Out-of-Pocket Limit/Individual | $6,250 | $15,000 |
| Annual Out-of-Pocket Limit/Family | $12,500 | $30,000 |
| Office Services | ||
| Office Visit/Exam | 20% After Deductible | 50% After Deductible |
| Specialist Visit | 20% After Deductible | 50% After Deductible |
| Urgent Care | 20% After Deductible | 50% After Deductible |
| Preventative Services | 100% Covered | 50% Coinsurance |
| Hospital Services | ||
| Inpatient Hospital | 20% After Deductible | 50% After Deductible |
| Outpatient Surgery | 20% After Deductible | 50% After Deductible |
| Emergency Room | 20% After Deductible | 50% After Deductible |
| Prescription Drugs | ||
| Retail (30-Days) Tier 1 | $10 After Deductible | $10 After Deductible |
| Retail (30-Days) Tier 2 | $35 After Deductible | $35 After Deductible |
| Retail (30-Days) Tier 3 | $60 After Deductible | $60 After Deductible |
| Mail Order (90-Day) | 2.5x Retail Copay | Not Covered |
