With the HSA Plan, you can see both in-network and out-of-network providers without a referral, but keep in mind staying in-network for care will almost always be less expensive. To help with your share of costs, this plan gives you the option to participate in a Health Savings Account (HSA).
HSA Plan | |
Where Available | Nationwide except HI |
Annual Deductible - Associate - Family | Aggregate $2,000 $4,0005 |
Annual Out-of-Pocket Max - Associate - Family | Embedded $6,000 $12,000 |
IN-NETWORK - YOU PAY | |
Preventive Care | $02 |
Teladoc Telemedicine Visit - Medical - Mental Health | $20 per visit (after deductible) $20 per visit (after deductible) |
Office Visit - PCP - Specialist | 20%1 20%1 |
Urgent Care | 20%1 |
Emergency Room | 20%1 |
Diagnostic Testing | 20%1 |
Outpatient X-Ray and Lab | 20%1 |
Hospitalization - Inpatient Semi-Private Room - Inpatient Physician | 20%1 20%1 |
Outpatient Treatment (Physical, Occupational & Speech Therapy) | 20%1 |
Mental Health/Substance Abuse - Inpatient - Outpatient | 20%1 20%1 |
Pharmacy Retail | 30-day supply |
- Annual Deductible Applies - Pharmacy Out-of-Pocket Max | Yes Combined with medical |
- Specified Preventive Drugs - Generic - Brand Preferred - Brand Non-Preferred | 100% covered2,3,4 $10 copay 20%1 (min $30, max $90) 30%1 (min $60, max $120) |
Pharmacy Retail/Mail Order | 90-day supply |
- Specified Preventive Drugs - Generic - Brand Preferred - Brand Non-Preferred | 100% covered2,3,4 $30 copay 20%1 (min $90, max $270) 30%1 (min $180, max $360) |
1) Coinsurance you pay after you meet the annual deductible unless otherwise noted.
2) Annual deductible waived.
3) As specified in essential drug list.
4) Includes additional preventive drugs based on a formulary.
5) The family deductible must be met before any person receives benefits.
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