Plan Details
Plan Name	PPO Saver/HSA Plan
Effective Dates	Jan 01, 2025 to Jan 01, 2026
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$1650 per individual / $3,300 per family member	$1650 per individual / $3,300 per family member
Annual Deductible/Family	$3,300	$3,300
Coinsurance	20%	40%
Office Visit/Exam	20%	40%
Outpatient Specialist Visit	20%	40%
Annual Out-of-Pocket Limit/Individual	$4500 per individual / $4,500 per family member	$4500 per individual / $4,500 per family member
Annual Out-of-Pocket Limit/Family	$6,850	$6,850
Preventive Care	0% ; deductible does not apply	40%
Inpatient Hospitalization	20%	40% subject to a benefit maximum of $600/day
Surgical Services Outpatient Facility Charge	20%	40% subject to a benefit maximum of $350/day
Emergency Room	20%	20%
Urgent Care Facility	20%	40%
Prescription Drug Deductible	Combined with medical deductible	Combined with medical deductible
Prescription Drugs - Generic	$10	Not Covered
Prescription Drugs - Brand (Formulary/Preferred)	$30	Not Covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$50	Not Covered
Prescription Drugs - Specialty	$100	Not Covered
Chiropractic Services	20% up to 20 visits per Member, per Calendar Year	40% up to 20 visits per Member, per Calendar Year
Acupuncture	Not Covered	Not Covered