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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