Annual Contribution

HSA

MHBP: (up to)

$845 (Self Only); $1,690 (Self & Family)

$845 (Self Only); $1,690 (Self & Family)

Member, Optional: (up to)

$2,055 (Self Only); $4,110 (Self & Family)

Not Applicable

Deductible

Self Only

Self and Family

Calendar-Year Deductible

$2,000

$4,000

Benefit Description

PPO

Routine Physical Exam & Immunizations

Nothing (No deductible)

Not Covered

Routine Preventive Screenings

Nothing (No deductible)

Not Covered

Benefit Description

Doctor's Office Visits

$15 copayment per office visits, including associated testing

40% of the Plan's allowance and any difference between our allowance and the billed amount

Lab, X-ray and Diagnostic Tests

$15 copayment per office visits, including associated testing

40% of the Plan's allowance and any difference between our allowance and the billed amount

Lab Savings Program

Nothing for covered lab tests with the Lab Savings Program with Quest^® Diagnostics

Chiropractic Care

$15 copayment per office visit, and all charges after
the Plan has paid the $2,500 combined alternative,
chiropractic and rehabilitative therapies maximum

40% of the Plan's allowance and any difference between our allowance and the billed amount, and all charges after
the Plan has paid the $2,500 combined alternative,
chiropractic and rehabilitative therapies maximum

Hospitalization

Nothing for covered room & board and $75 per day up to $750 for hospital ancillary services

40% of the Plan's allowance and any difference between our allowance and the billed amount

Outpatient Surgical Facility

$150 copayment per occurrence

40% of the Plan's allowance and any difference between our allowance and the billed amount

Surgery and Anesthesia

Nothing in hospital; $15 copayment in doctor's office

40% of the Plan's allowance and any difference between our allowance and the billed amount

Emergency Treatment

$50 copayment per occurrence

40% of the Plan's allowance and any difference between our allowance and the billed amount

Overseas Medical Expenses

PPO-level benefits for covered care received outside of the United States

Catastrophic protection
(Some costs do not count toward this protection)

Nothing after your out-of-pocket expenses for covered services from PPO providers totals $5,000 per calendar year for Self Only enrollment ($10,000 for Self and Family enrollment)

Nothing after your out-of-pocket expenses for covered services from PPO providers and non-PPO providers combined totals $7,500 per calendar year for Self Only enrollment ($15,000 for Self and Family enrollment)

Benefit Description

Generic

$10 copayment

Not covered

Preferred brand name

$25 copayment

Not covered

Non-Preferred brand name

$40 copayment

Not covered

Generic

$20 copayment

Not covered

Preferred brand name

$50 copayment

Not covered

Non-Preferred brand name

$80 copayment

Not covered

Vision care discounts and savings from EyeMed Vision Care providers, laser vision correction savings from the U.S. Laser Network and QualSight, and a hearing aid discount program from HearPO.*