Medical Plan Comparison

 

HDHP/HSA

Traditional PPO

Buy-Up PPO

In-Network
Non-Network
In-Network
Non-Network
In-Network
Non-Network
Employer Health Savings Account (HSA) Match Contribution 1/1/21 Prorated for New Hires
    Single

Up To $500

Not Applicable

Not Applicable

    Family

Up To $500

Not Applicable

Not Applicable

DEDUCTIBLES
    Single

$2,800

$2,500

$1,500

    Family

$5,600

$5,000

$3,000

OUT-OF-POCKET MAXIMUMS (includes deductible)
    Single
$2,800 $13,000 $6,350 $12,700 $5,000 $10,000
    Family
$5,600 $26,000$12,700 $25,400$10,000 $20,000
PLAN CO-PAYMENTS
    Office Visit (includes lab services performed in office or network lab)
0% after deductible40% after deductible$35 copay60% after deductible$35 copay50% after deductible
    Emergency Room

0% after deductible

$200 copay, plus 30% after deductible

$200 copay, plus 20% after deductible

    Inpatient or Outpatient Services
0% after deductible40% after deductible30% after deductible60% after deductible20% after deductible50% after deductible
    Urgent Care Visit
0% after deductible40% after deductible$70 copay60% after deductible$70 copay50% after deductible
PRESCRIPTION DRUG COPAY (34 day supply)
    Tier 1 - Retail Generic

0% after deductible

N/A

$10 copay

N/A

$10 copay

N/A

    Tier 2 -Retail Preferred Brand

0% after deductible

$40 copay$40 copay

N/A

    Tier 3 - Retail Non-Preferred

0% after deductible

50% coinsurance50% coinsurance

N/A