This PPO plan includes an HSA in which You can contribute pre-tax dollars to use for eligible medical expenses. Each time you visit the doctor or receive health care services, you can use your pre-tax dollars towards the expenses. The HSA covers incurred expenses by paying them from this allocation until the contribution dollars are exhausted.
| 2025 HSA Plan Rates | ||||||
|---|---|---|---|---|---|---|
| Salary <$50,000 | Salary $50,000 - $100,000 | Salary >$100,000 | ||||
| Weekly | Bi-Weekly | Weekly | Bi-Weekly | Weekly | Bi-Weekly | |
| Employee Only | $19.34 | $38.68 | $21.04 | $42.09 | $21.04 | $42.09 |
| Employee + Spouse | $65.24 | $130.49 | $104.96 | $209.91 | $111.98 | $223.95 |
| Employee + Child(ren) | $53.38 | $106.76 | $85.87 | $171.74 | $91.62 | $183.23 |
| Employee + Family | $91.93 | $183.86 | $147.89 | $295.78 | $157.79 | $315.57 |
| PPO with HSA Information | ||
|---|---|---|
|
You can contribute to your HSA, up to $4,300 for employee only coverage or $8,550 for family coverage. If you are over the age of 55 you can contribute an additional $1,000 catch-up contribution. |
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| In Network | Out Of Network | |
| General Services | ||
| Annual Deductible/Individual | $3,300 | $6,400 |
| Annual Deductible/Family | $6,000 | $12,000 |
| Annual Out-of-Pocket Limit/Individual | $6,000 | $15,000 |
| Annual Out-of-Pocket Limit/Family | $12,000 | $30,000 |
| Office Services | ||
| Office Visit/Exam | 20% After Deductible | 50% After Deductible |
| Virtual Visits | $54 copay until the deductible is met | |
| Specialist Visit | 20% After Deductible | 50% After Deductible |
| Urgent Care | 20% After Deductible | 50% After Deductible |
| Preventative Services | 100% Covered | 100% Covered |
| Hospital Services | ||
| Inpatient Hospital | 20% After Deductible | 50% After Deductible |
| Outpatient Surgery | 20% After Deductible | 50% After Deductible |
| Emergency Room | 20% After Deductible | 50% After Deductible |
Along the way, you may also be required to pay a fixed amount – or copay – each time you see a provider.
