COMPARE NUMBERS
What You Pay for Services
| 2023 | 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 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.
