| |
HSA Plans |
Annual Deductible
Individual deductible/Family Deductible |
HSA 1200 - $1,200/$2,400
HSA 2500 - $2,500/$5,000 |
Annual Out-of-Pocket Maximum
Individual out-of-pocket maximum/
Family out-of-pocket maximum |
HSA 1200 - $5,250/$10,500
HSA 2500 - $5,000/$10,000 |
| Lifetime Maximum |
$2 million per person
(up to $25,000 of total amount of benefits paid will be restored to Lifetime Maximum every calendar year) |
| Accidental Injury Benefit |
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 †. |
| Preventive Care |
In-Plan |
Out-of-Plan |
| Periodic health exams, well-baby care |
$20 copay † |
40% |
| Women's annual gynecological exam |
$20 copay † |
40% |
| Follow-up visits after annual gynecological exam |
$20 copay † |
40% |
| Mammograms |
$20 copay † |
40% |
|
Physician/Provider Services |
| Office visits to a personal physician/provider |
$20 copay |
40% |
| Office visits to specialists |
20% |
40%
|
| Other services, including inpatient hospital visits |
20% |
40% |
| Routine immunizations/shots |
$20 copay † |
40% |
| Hospital Services |
| Acute care |
20% |
40% |
Skilled nursing facility
(see limitations) |
20% |
40% |
| Maternity Care |
| Provider & hospital services |
20% |
40% |
| Emergent/Urgent care |
| Emergency services |
$125 |
| Urgent care services |
20% |
Ambulance services
(see limitations) |
20% |
| Other Covered Services |
Durable medical equipment & medical supplies
(see limitations) |
20% |
40% |
Outpatient rehabilitative services
(see limitations) |
20% |
40% |
Laboratory & x-ray
Outpatient surgery, Radiation therapy, Chemotherapy |
20% |
40% |
Home health care
(see limitations) |
20% |
40% |
Mental health and alcohol treatment
(see limitations) |
20% |
40% |
| Prescription Drugs |
| Covered at participating pharmacies
at the In-Plan benefit only |
Generic and brand-name drugs
(up to a 30-day supply) - 50% |
| A 90-day supply of certain maintenance
drugs may be purchased at a participating mail order pharmacy. |
Plan Updates 
