| |
HSA 2500 |
HSA 3500 |
Annual Deductible
Individual/Family |
$2,500/$5,000 |
$3,500/$7,000 |
Annual Out-of-Pocket Maximum
Individual/Family |
$5,000/$10,000 |
$5,950/$11,900 |
| Essential Health Benefit Maximum |
$1,250,000 plan year aggregate limit |
$1,250,000 plan year aggregate limit |
| Accidental Injury Benefit |
Does not apply |
Does not apply |
After meeting your deductible, you pay the following
amounts for covered services:
(The deductible is waived for some covered services. These services are marked with †. |
| |
In-Plan |
Out-of-Plan |
In-Plan |
Out-of-Plan |
| Preventive Care |
| Periodic health exams, well-baby care |
Covered in full † |
40% |
Covered in full † |
50% |
| Routine immunizations/shots |
Covered in full † |
40% |
Covered in full † |
50% |
| Mammograms |
Covered in full † |
40% |
Covered in full † |
50% |
| Gynecological exams, Pap tests |
Covered in full † |
40% |
Covered in full † |
50% |
|
Physician/Provider Services |
| Office visits |
$20 copay |
40% |
50% |
50% |
| Office visits to specialists |
20% |
40% |
50% |
50% |
| Inpatient hospital visits, surgery, anesthesia |
20% |
40% |
50% |
50% |
| Hospital Services |
| Inpatient and observation care |
20% |
40% |
50% |
50% |
| Maternity care |
20% |
40% |
50% |
50% |
| Routine newborn nursery care |
20% |
40% |
50% |
50% |
| Rehabilitative care |
20% |
40% |
50% |
50% |
| Emergency/Urgent care |
| Emergency services |
$250 copay |
50% |
50% |
| Urgent care services |
$20 copay |
40% |
50% |
50% |
| Emergency transportation |
20% |
20% |
50% |
50% |
| Outpatient Diagnostic Services |
| X-ray; lab services |
20% |
40% |
50% |
50% |
| Imaging services (PET, CT, MRI) |
20% |
40% |
50% |
50% |
| Other Covered Services |
| Medical & Diabetes Supplies |
20% |
40% |
50% |
50% |
| Outpatient surgery, radiation therapy, chemotherapy |
20% |
40% |
50% |
50% |
Mental health & alcohol treatment |
20% |
40% |
50% |
50% |
| Prescription Drugs |
| Covered at participating retail and mail-order pharmacies only |
Generic and brand-name drugs
(up to a 30-day supply) - 50% |
| Alternative care services |
| Acupuncture, chiropractic care, massage therapy and dietitian services |
Receive 25% off provider rates through the Choose Healthy network. |
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