8
HSA-Eligible PPO Plan Design
Benefit
In-Network
Deductible
Annual Out-of-Pocket
Maximum
Office Visit*
Lab and X-Ray*
Hospital Inpatient*
LASIK
Body Scan
Chiropractic/Acupuncture*
Prescription Drugs*
$1,500 single
$2,600 individual on family plan
$3,000 family
$2,600 single
$2,600 individual on family plan
$5,000 family
20%
20%
20%
$1,500 lifetime benefit
per eye
Once every 24 months,
member and spouse only
20%
$10 for generics**
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*After deductible has been met
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**Effective 1/1/17, now uses Essential Drug List