This plan exclusively covers you for in-network doctors and facilities. Except in the case of an emergency, you’ll pay the full price for any out-of-network care. To help with your share of costs, this plan comes with a Health Savings Account (HSA) that you can contribute to.
| 2022 EPO 2000 WITH HSA PLAN HIGHLIGHTS | |
|---|---|
| Provider Network | Extensive national network of contracted providers. |
| Primary Care Physician (PCP) to manage care | Not required |
| Referrals needed to see a specialist | Not required |
| Calendar Year Deductible | $2,000 per individual/$4,000 per family1 |
| Health Savings Account (HSA) | Yes. You can contribute pre-tax dollars to an HSA through HealthEquity. IRS limits for 2020 are $3,550 (employee only) and $7,100 (family). You can contribute an additional $1,000 if you are age 55 or older in 2020. Learn more |
| Coinsurance (You Pay) After Meeting Deductible | 20% |
| Calendar Year Out-of-Pocket Maximum | $6,000 per individual/$12,000 per family |
| Preventive Care | Covered in full (calendar year deductible waived) |
| Office Visit (You Pay) | 20%2 |
| Hospitalization | 20%2 |
| Pharmacy Retail (30-day supply) |
Network pharmacy: specified preventive drugs—100% covered3; generic—$10 copay2; brand formulary—$25 copay2; brand non-formulary—$40 copay2; specialty drugs-20%2,5 up to $125
|
| Pharmacy Mail Services (up to 90-day supply) |
Network pharmacy: specified preventive drugs—100% covered3; generic—$20 copay2; brand formulary—$50 copay2; brand non-formulary—$80 copay2
|
- The family deductible must be met before any person receives benefits.
- After calendar year deductible.
- Calendar year deductible waived.
- As specified in drug list.
- May be available at CerpassRx retail pharmacy or Pharmacy Mail Service if authorized. Note that any specialty drug discounts through copay cards or coupons will not apply towards the calendar year deductible our out-of-pocket maximum.