| |
HSA PPO |
Plan year deductible
(family deductible is 2x the individual) |
$2,800 (individual)
$5,600 (family) |
Out-of-Pocket Maximum, Per Member
(after deductible) |
$2,200 (individual)
$4,400 (family) |
No maximum |
| Plan Year Essential Benefit Maximum |
$2,000,000 |
| Preventive Care |
Member Responsibility |
| The deductible is waived for in-network preventive care. |
In Network Provider |
Out of Network Provider |
| Annual women’s exam -Pap, pelvic, breast |
$0* |
50% |
| Women's routine mammogram |
$0* |
50% |
| Well-baby care |
$0* |
50% |
| Routine Physical Exams |
$0* |
50% |
| Immunizations |
$0* |
50% |
| Professional Services |
| Office Visits |
50% |
50% |
Alternative care ($1,000 per plan year limit)
Chiropractic, naturopathic and acupuncture |
50% |
50% |
| Facility and Ancillary Services |
| Hospital - Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care |
50% |
50% |
| Maternity - All pre/post office visits and doctor delivery; hospital charges |
50% |
50% |
Mental health - Inpatient, outpatient, residential
(see limitations and exclusions) |
50% |
50% |
Alcohol / Mental Health Treatment
Inpatient, outpatient, residential combined |
50% |
50% |
| Lab and X-ray services; rehabilitation services; medical supplies and devices; in-hospital care; home healthcare |
50% |
50% |
Vision
(see limitations and exclusions) |
Not covered |
| Emergency Services |
| Urgent care |
50% |
50% |
| Emergency room (deductible applies) |
50% |
| Ambulance ($5,000 per plan year limit) |
50% |
| Other Benefits |
| Prescription services |
50% |
| Accident benefit |
Paid as any other illness subject to deductible/coinsurance |
| *Deductible waived |
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