HSA PPO Plan

Health Savings Account PPO Plan

The Health Savings Account – PPO lets you control your healthcare expenses. This option combines the features of a Health Savings Account for your day-to-day medical expenses and the required high deductible plan to cover catastrophic expenses. This option is available only to employees not covered by a collective bargaining agreement.

Deductible applies to all network and non-network services.
Health Savings Account Company Contribution Employee Contribution	$500 Individual / $1,000 Family up to $2,800 Individual / $5,550 Family
Summary of Benefits	Network Provider	Non-Network Provider
Physician Services Primary Care Physicians Specialists	80%	60% of MNRP*
Preventive Care	$25 co-payment (deductible does not apply)	None
Well Baby Care	Included in Preventive Care (deductible does not apply)	None
Hospital Inpatient	80%	60% of MNRP*
Hospital Outpatient	80%	60% of MNRP*
Emergency Room	80% for emergencies 60% for non-emergencies	80% of MNRP* for emergencies 60% of MNRP* for non-emergencies
Urgent Care Centers	80%	60% MNRP*
Surgery	80%	60% MNRP*
X-ray & laboratory	80%	60% MNRP*
Prescription Drugs (one month supply)	Tier 1: 80% ($25 min/$45 max) Tier 2: 60% ($45 min/$70 max) Tier 3: 50% ($70 min/$95 max)	Not covered
Mail Order Prescription (3 month Supply)	Tier 1: 80% ($45 min/$90 max) Tier 2: 60% ($90 min/$140 max) Tier 3: 50% ($140min/$190 max)	Not covered
Mental Health & Chemical Dependency	Inpatient 50% Outpatient 50%	Inpatient 50% Outpatient 50%
Deductible **	$1,550/person $3,100/family	$3,100/person $6,200/family
Co-insurance maximum	$4,300/person $8,600/ family	$6,200/person $12,4000/ family
Life time maximum	none

* Maximum Non-network Reimbursement Program (MNRP) as determined by United Health Care

** Deductible does not apply to network providers except where noted. The deductible applies in most situation when using a non-network provider.

Employee Bi-Weekly Cost (Effective January 1, 2015)

Employee Only	$47.29/bi-weekly
Employee & Child(ren)	$82.23/bi-weekly
Employee & Spouse	$99.49/bi-weekly
Employee, Spouse & Child(ren)	$147.49/bi-weekly

Revised: July 22, 2015.