With this option, you can see both in-network and out-of-network doctors without a referral, but keep in mind staying in-network for care will almost always be cheaper. To help with your share of costs, this plan comes with a Health Savings Account (HSA) that you can contribute to.
|PPO 5000 WITH HSA PLAN HIGHLIGHTS|
|Provider network||Extensive national network of contracted providers. Benefits are higher when you use in-network PPO providers.|
|Primary Care Physician (PCP) to manage care||Not required|
|Referrals needed to see a specialist||Not required|
|Calendar Year Deductible||
In-network: $5,000 per individual1/$10,000 per family1,2
|Health Savings Account (HSA)||Yes. You can contribute pre-tax dollars to an HSA through HealthEquity. IRS limits for 2019 are $3,500 (employee only) and $7,000 (family). You can contribute an additional $1,000 if you are age 55 or older in 2019. Learn more|
|Coinsurance (You Pay) After Meeting Deductible||
|Calendar Year Out-of-Pocket Maximum||
In-network: $6,550 per individual3/$13,100 per family3
In-network: Covered in full (calendar year deductible waived)
In-network: PCP: 20%4, Specialist: 20%4
Network pharmacy: specified preventive drugs—100% covered; generic—$10 copay4; brand formulary—$25 copay4; brand non-formulary—$40 copay4
|Pharmacy Mail Services
(up to 90-day supply)
Network pharmacy: specified preventive drugs—100% covered; generic—$20 copay4; brand formulary—$50 copay4; brand non-formulary—$80 copay4
- In-network calendar year deductible is separate from out-of-network calendar year deductible and does not cross accumulate. Refer to the PPO 5000 Summary of Benefits and Coverage (SBC) for information on out-of-network deductible amounts.
- The family deductible must be met before any person receives benefits.
- In-network calendar year out-of-pocket maximum is separate from out-of-network calendar year out-of-pocket maximum and does not cross accumulate. Refer to the PPO 5000 Summary of Benefits and Coverage (SBC) for information on out-of-network out-of-pocket maximum amounts.
- After calendar year deductible.
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