Health Insurance, continued Compare Health Insurance Plans, continued The percentages in the following table are the percentages you pay. For example, if you see “20%” that means the plan pays 80% and the remaining 20% is your responsibility. If you see “100% covered” that means there is no member responsibility for that type of care or service. Anytime you see “after deductible is met,” that means the annual medical deductible for the plan must be met before the plan will pay. Please keep in mind that these do not re昀氀ect any services not covered by the plan or bene昀椀t reductions caused by not complying with preauthorization. HEALTH SAVINGS PLAN NETWORK PLAN (HSA) Network Facilities and Providers Network Facilities and Providers Wellness and Preventive Care 100% Covered 100% Covered Annual Medical Deductible Individual Limit $2,000 $900 Family Limit $3,500 $1,800 Annual Out-of-Pocket Limit (includes medical deductible) Individual Limit $4,250 $3,125 Family Limit $7,000 $6,750 Of昀椀ce Visits $10 or $50 copay Primary Care Provider (PCP) 20% after deductible is met (See zip code table to determine if higher copay applies) Specialist 20% after deductible is met $50 copay Chiropractic Care 20% after deductible is met $10 copay (Up to 5 visits per year) Infertility Services 20% after deductible is met, up 20% after deductible is met, up to a $15,000 lifetime maximum to a $15,000 lifetime maximum Urgent Care 20% after deductible is met $20 copay* Emergency Room Services 20% after deductible is met 1-3 visits: $150 copay, then 20% after deductible is met 4-5 visits: $400 copay, then 30% after deductible is met 6 or more visits: $600 copay, then 40% after deductible is met * Primary Care Provider (PCP) copay may apply at some locations if not able to bill as urgent care. | 8 |