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 $2,400 Individual / $4,800 Family
Summary of Benefits	Network Provider	Non-Network Provider
Physician Services Primary Care Physicians Specialists	80%	60% of MNRP*
Preventive Care	$25 co-payment (up to $300/person per calendar year)	None
Well Baby Care	Included in Preventive Care	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% ($20 min/$40/max) Tier 2: 60% ($40 min/$60 max) Tier 3: 50% ($60 min/$80 max)	Not covered
Mail Order Prescription (3 month Supply)	Tier 1: 80% ($40 min/$80/max) Tier 2: 60% ($80 min/$120/max) Tier 3: 50% ($120min/$160 max)	Not covered
Mental Health & Chemical Dependency	Inpatient 50% Outpatient 50%	Inpatient 50% up to $400/day Outpatient 50% up to $40/visit
Deductible **	$1250/person $2500/family	$2500/person $5000/family
Co-insurance maximum	$3,500/person $7,000/ family	$5,000/person $10,000/ family
Life time maximum	$2,000,000/person

* 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, 2010)

Employee Only	$34.47/bi-weekly
Employee & Child(ren)	$59.94/bi-weekly
Employee & Spouse	$72.52/bi-weekly
Employee, Spouse & Child(ren)	$107.51/bi-weekly

Revised: July 30, 2010.