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.

2021 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 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 2019. Learn more
Coinsurance (You Pay) After Meeting Deductible
In-network: 20%
Calendar Year Out-of-Pocket Maximum
In-network: $6,550 per individual3/$13,100 per family3
Preventive Care
In-network: Covered in full (calendar year deductible waived)
Office Visit
In-network: PCP: 20%4, Specialist: 20%4
Hospitalization
In-network: 20%4
Pharmacy Retail
(30-day supply)
Network pharmacy: specified preventive drugs—100% covered; generic—$10 copay4; brand formulary—$25 copay4; brand non-formulary—$40 copay4; specialty drugs-20%4,5 up to $125
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
  1. 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.
  2. The family deductible must be met before any person receives benefits.
  3. 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.
  4. After calendar year deductible.
  5. May be available at CVS 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.

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