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	$1650 per individual
Annual Deductible/Family	$3300 per family for participating providers	$3300 per family for non-participating providers
Coinsurance	20%	40%
Office Visit/Exam	20%	40%
Outpatient Specialist Visit	20%	40% subject to benefit max $350/per day
Annual Out-of-Pocket Limit/Individual	$4500 per individual	$4500 per individual
Annual Out-of-Pocket Limit/Family	$6850 per family for participating providers	$6850 per family for non-participating providers
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 Retail: /prescription	Not Covered
Prescription Drugs - Brand (Formulary/Preferred)	$30 Retail: /prescription	Not Covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$50 Retail: /prescription	Not Covered
Prescription Drugs - Specialty	$100 Retail and Network Specialty Pharmacies: /prescription	Not Covered
Chiropractic Services	20% up to 20 visits per year	40% up to 20 visits per year
Acupuncture	Not Covered	Not Covered