Health :: Compare Numbers

COMPARE NUMBERS

What You Pay for Services

2021BASIC HSAHSA PLUSBASIC PPOCLASSIC 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 CareIn-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 PhysicianNo 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 OnlineIn-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.