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What You Pay for Services

2024	BASIC HSA	HSA PLUS	BASIC PPO	CLASSIC PPO
XPO HSA Contribution	The Basic HSA does not get an XPO contribution.	Individual: $500 Employee + One or More: $1,000	The Basic PPO does not include an HSA.	The Classic PPO does not include an HSA.
Annual Deductible (Individual/Employee + One or More)	In-Network: $2,500/$5,000 Out-of-Network: $5,000/$10,000	In-Network: $1,750/$3,500 Out-of-Network: $3,500/$7,000	In-Network: $1,250/$2,500 Out-of-Network: $2,500/$5,000	In-Network: $900/$1,800 Out-of-Network: $1,800/$3,600
Coinsurance (after you meet the deductible)	In-Network: You Pay: 30% XPO Pays: 70% Out-of-Network: You Pay: 50% XPO Pays: 50%	In-Network: You Pay: 20% XPO Pays: 80% Out-of-Network: You Pay: 50% XPO Pays: 50%	In-Network: You Pay: 20% XPO Pays: 80% Out-of-Network: You Pay: 50% XPO Pays: 50%	In-Network: You Pay: 20% XPO Pays: 80% Out-of-Network: You Pay: 50% XPO Pays: 50%
Annual Out-of-Pocket Maximum (Individual/Employee + One or More)	In-Network: $5,000/$10,000 Out-of-Network: $10,000/$20,000	In-Network: $5,000/$10,000 Out-of-Network: $10,000/$20,000	In-Network: $5,000/$10,000 Out-of-Network: $10,000/$20,000	In-Network: $5,000/$10,000 Out-of-Network: $10,000/$20,000
Preventive Care	In-Network: No copay. XPO pays 100% of the cost. Out-of-Network: Not covered.	In-Network: No copay. XPO pays 100% of the cost. Out-of-Network: Not covered.	In-Network: No copay. XPO pays 100% of the cost. Out-of-Network: Not covered.	In-Network: No copay. XPO pays 100% of the cost. Out-of-Network: Not covered.
Primary Care Physician	No copay. Coinsurance applies.	No copay. Coinsurance applies.	In-Network: $35 copay Out-of-Network: No copay. Coinsurance applies.	In-Network: $35 copay Out-of-Network: No copay. Coinsurance applies.
Specialist	No copay. Coinsurance applies.	No copay. Coinsurance applies.	In-Network: $55 copay Out-of-Network: No copay. Coinsurance applies.	In-Network: $55 copay Out-of-Network: No copay. Coinsurance applies.
LiveHealth Online	In-Network: 30% after deductible Out-of-Network: Not covered.	In-Network: 20% after deductible Out-of-Network: Not covered.	In-Network: $10 copay Out-of-Network: Not covered.	In-Network: $10 copay Out-of-Network: Not covered.
Urgent Care (facility only)	No copay. Coinsurance applies.	No copay. Coinsurance applies.	$60 copay	$60 copay
Emergency Room (facility only)	No copay. Coinsurance applies.	No copay. Coinsurance applies.	$150 copay. Coinsurance applies.	$150 copay. Coinsurance applies.
Inpatient Hospital (includes behavioral health)	No copay. Coinsurance applies.	No copay. Coinsurance applies.	No copay. Coinsurance applies.	No copay. Coinsurance applies.
Physician Services (inpatient/outpatient)	No copay. Coinsurance applies.	No copay. Coinsurance applies.	No copay. Coinsurance applies.	No copay. Coinsurance applies.

A Note About HSA Plus Contributions: XPO HSA contribution amounts are prorated based on when you become eligible for benefits or have Qualifying Event changes.

A Note About Meeting the Family Deductible and Out-of-Pocket Maximum: To learn how one family member can meet the deductible and out-of-pocket maximum for the entire family, review the Medical FAQs.

A Note About Out-of-Network Expenses: Out-of-Network expenses are limited to the eligible maximum allowed amount. You are responsible for paying any amount over the eligible maximum allowed amount charges in addition to your deductible and coinsurance.

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