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
Employee Cost $
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
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
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.

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