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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A PPO PROVIDER

*After deductible has been met

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**Effective 1/1/17, now uses Essential Drug List