High Deductible Health Plan
Qualified High Deductible Plan with a Health Savings Account feature. Network: Aetna · Administrator: Aetna
High Deductible Health Plan
Plan Details
HSA Eligible
Yes
FSA Eligible
No
Medical Premiums - HDHP Plan
| Coverage Tier | Salaried (Semi-Monthly) | Hourly (Weekly) |
|---|---|---|
| Employee Only | Engaged Tier 1 $20-59.99k$15.00 $60-99.99k$25.00 $100k+$35.00 Engaged Tier 2 $20-59.99k$35.00 $60-99.99k$45.00 $100k+$55.00 Non-Engaged $20-59.99k$83.00 $60-99.99k$249.00 $100k+$314.74 | Engaged Tier 1 $20-59.99k$6.92 $60-99.99k$11.54 $100k+$16.15 Engaged Tier 2 $20-59.99k$16.15 $60-99.99k$20.77 $100k+$25.38 Non-Engaged $20-59.99k$38.31 $60-99.99k$114.92 $100k+$145.26 |
| Employee + Spouse | Engaged Tier 1 $20-59.99k$40.00 $60-99.99k$60.00 $100k+$80.00 Engaged Tier 2 $20-59.99k$60.00 $60-99.99k$80.00 $100k+$100.00 Non-Engaged $20-59.99k$320.10 $60-99.99k$356.40 $100k+$392.70 | Engaged Tier 1 $20-59.99k$18.46 $60-99.99k$27.69 $100k+$36.92 Engaged Tier 2 $20-59.99k$27.69 $60-99.99k$36.92 $100k+$46.15 Non-Engaged $20-59.99k$147.74 $60-99.99k$164.49 $100k+$181.25 |
| Employee + Children / Family | Engaged Tier 1 $20-59.99k$60.00 $60-99.99k$90.00 $100k+$120.00 Engaged Tier 2 $20-59.99k$80.00 $60-99.99k$110.00 $100k+$140.00 Non-Engaged $20-59.99k$360.11 $60-99.99k$414.56 $100k+$469.01 | Engaged Tier 1 $20-59.99k$27.69 $60-99.99k$41.54 $100k+$55.38 Engaged Tier 2 $20-59.99k$36.92 $60-99.99k$50.77 $100k+$64.62 Non-Engaged $20-59.99k$166.21 $60-99.99k$191.34 $100k+$216.47 |
Employee Only
Salaried (Semi-Monthly)
Engaged Tier 1
$20-59.99k$15.00
$60-99.99k$25.00
$100k+$35.00
Engaged Tier 2
$20-59.99k$35.00
$60-99.99k$45.00
$100k+$55.00
Non-Engaged
$20-59.99k$83.00
$60-99.99k$249.00
$100k+$314.74
Hourly (Weekly)
Engaged Tier 1
$20-59.99k$6.92
$60-99.99k$11.54
$100k+$16.15
Engaged Tier 2
$20-59.99k$16.15
$60-99.99k$20.77
$100k+$25.38
Non-Engaged
$20-59.99k$38.31
$60-99.99k$114.92
$100k+$145.26
Employee + Spouse
Salaried (Semi-Monthly)
Engaged Tier 1
$20-59.99k$40.00
$60-99.99k$60.00
$100k+$80.00
Engaged Tier 2
$20-59.99k$60.00
$60-99.99k$80.00
$100k+$100.00
Non-Engaged
$20-59.99k$320.10
$60-99.99k$356.40
$100k+$392.70
Hourly (Weekly)
Engaged Tier 1
$20-59.99k$18.46
$60-99.99k$27.69
$100k+$36.92
Engaged Tier 2
$20-59.99k$27.69
$60-99.99k$36.92
$100k+$46.15
Non-Engaged
$20-59.99k$147.74
$60-99.99k$164.49
$100k+$181.25
Employee + Children / Family
Salaried (Semi-Monthly)
Engaged Tier 1
$20-59.99k$60.00
$60-99.99k$90.00
$100k+$120.00
Engaged Tier 2
$20-59.99k$80.00
$60-99.99k$110.00
$100k+$140.00
Non-Engaged
$20-59.99k$360.11
$60-99.99k$414.56
$100k+$469.01
Hourly (Weekly)
Engaged Tier 1
$20-59.99k$27.69
$60-99.99k$41.54
$100k+$55.38
Engaged Tier 2
$20-59.99k$36.92
$60-99.99k$50.77
$100k+$64.62
Non-Engaged
$20-59.99k$166.21
$60-99.99k$191.34
$100k+$216.47
Deductible - Out of Pocket & Coinsurance
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Individual) | $2,500 | $5,000 |
| Deductible (Family ) | $5,000 | $10,000 |
| Out-of-Pocket Max (Individual) | $6,650 | $13,300 |
| Out-of-Pocket Max (Family ) | $13,300 | $26,600 |
| Coinsurance (Plan Pays) | 80% | 50% |
Deductible (Individual)
In-Network$2,500
Out-of-Network$5,000
Deductible (Family )
In-Network$5,000
Out-of-Network$10,000
Out-of-Pocket Max (Individual)
In-Network$6,650
Out-of-Network$13,300
Out-of-Pocket Max (Family )
In-Network$13,300
Out-of-Network$26,600
Coinsurance (Plan Pays)
In-Network80%
Out-of-Network50%
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | No Charge | 50% after deductible |
| Primary Care Visit | 20% after deductible | 50% after deductible |
| Specialist Visit | 20% after deductible | 50% after deductible |
| Diagnostic Care | 20% after deductible | 50% after deductible |
| Urgent Care | 20% after deductible | 50% after deductible |
| Emergency Room | 20% after deductible | 20% after deductible |
Preventive Care
In-NetworkNo Charge
Out-of-Network50% after deductible
Primary Care Visit
In-Network20% after deductible
Out-of-Network50% after deductible
Specialist Visit
In-Network20% after deductible
Out-of-Network50% after deductible
Diagnostic Care
In-Network20% after deductible
Out-of-Network50% after deductible
Urgent Care
In-Network20% after deductible
Out-of-Network50% after deductible
Emergency Room
In-Network20% after deductible
Out-of-Network20% after deductible
Pharmacy Benefits
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Retail (30-day)- Generic | $10 copay after deductible | 50% after deductible |
| Retail (30-day)- Preferred Brand | $30 copay after deductible | 50% after deductible |
| Retail (30-day)- Non-Preferred Brand | $60 copay after deductible | 50% after deductible |
| Mail Order (90-day) - Tier 1 | $20 copay after deductible | Not covered |
| Mail Order (90-day) - Tier 2 | $60 copay after deductible | Not covered |
| Mail Order (90-day) - Tier 3 | $120 copay after deductible | Not covered |
Retail (30-day)- Generic
In-Network$10 copay after deductible
Out-of-Network50% after deductible
Retail (30-day)- Preferred Brand
In-Network$30 copay after deductible
Out-of-Network50% after deductible
Retail (30-day)- Non-Preferred Brand
In-Network$60 copay after deductible
Out-of-Network50% after deductible
Mail Order (90-day) - Tier 1
In-Network$20 copay after deductible
Out-of-NetworkNot covered
Mail Order (90-day) - Tier 2
In-Network$60 copay after deductible
Out-of-NetworkNot covered
Mail Order (90-day) - Tier 3
In-Network$120 copay after deductible
Out-of-NetworkNot covered
Plan Notes
- Inpatient services: 20% after deductible in-network; 50% after deductible out-of-network
- Outpatient services: 20% after deductible in-network; 50% after deductible out-of-network
- Pairs with HSA; employer makes monthly HSA contributions based on wellness engagement tier