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. |