Compare Numbers

What You Pay for Services

2021BASIC HSAHSA PLUSBASIC PPOCLASSIC PPO
Annual Deductible
(Individual/Employee + One or More)
In-Network:
$2,500/$5,000 integrated with medical

Out-of-Network:
$5,000/$10,000 integrated with medical
In-Network:
$1,750/$3,500 integrated with medical

Out-of-Network:
$3,500/$7,000 integrated with medical
Not applicableNot applicable
Annual Out-of-Pocket Maximum
(Individual/Employee + One or More)
In-Network:
$5,000/$10,000 integrated with medical

Out-of-Network:
$10,000/$20,000
integrated with medical
In-Network:
$5,000/$10,000 integrated with medical

Out-of-Network:
$10,000/$20,000
integrated with medical
In-Network:
$5,000/$10,000 integrated with medical

Out-of-Network:
$10,000/$20,000
integrated with medical
In-Network:
$5,000/$10,000 integrated with medical

Out-of-Network:
$10,000/$20,000
integrated with medical
Preventive$10 maximum; no deductible$10 maximum; no deductible$10 maximum; no deductible$10 maximum; no deductible
Preventive Brand Formulary30% coinsurance; no deductible (minimum $35; maximum $70)30% coinsurance; no deductible (minimum $35; maximum $70)30% coinsurance; no deductible (minimum $35; maximum $70)30% coinsurance; no deductible (minimum $35; maximum $70)
Preventive Brand Non-Formulary50% coinsurance; no deductible (minimum $70; maximum $140)50% coinsurance; no deductible (minimum $70; maximum $140)50% coinsurance; no deductible (minimum $70; maximum $140)50% coinsurance; no deductible (minimum $70; maximum $140)
Generic Retail
(30-Day Supply)
$10 maximum
after deductible
$10 maximum
after deductible
$10 maximum; no deductible$10 maximum; no deductible
Brand Formulary Retail (30-Day Supply)30% coinsurance after deductible (minimum $35; maximum $70)30% coinsurance after deductible (minimum $35; maximum $70)30% coinsurance; no deductible (minimum $35; maximum $70)30% coinsurance; no deductible (minimum $35; maximum $70)
Brand Non-Formulary Retail
(30-Day Supply)
50% coinsurance after deductible (minimum $70; maximum $140)50% coinsurance after deductible (minimum $70; maximum $140)50% coinsurance; no deductible (minimum $70; maximum $140)50% coinsurance; no deductible (minimum $70; maximum $140)
Generic Mail Order
(90-Day Supply)
$25 copay after deductible$25 copay after deductible$25 copay; no deductible$25 copay; no deductible
Brand Formulary Mail Order
(90-Day Supply)
30% coinsurance after deductible (minimum $90; maximum $180)30% coinsurance after deductible (minimum $90; maximum $180)30% coinsurance; no deductible (minimum $90; maximum $180)30% coinsurance; no deductible (minimum $90; maximum $180)
Brand Non-Formulary Mail Order
(90-Day Supply)
50% coinsurance after deductible (minimum $175; maximum $350)50% coinsurance after deductible (minimum $175; maximum $350)50% coinsurance; no deductible (minimum $175; maximum $350)50% coinsurance; no deductible (minimum $175; maximum $350)

A note about preventive medications: Under the Basic HSA and HSA Plus options, the deductible does not need to be met for preventive drugs as defined by Express Scripts in the 2020 preventive drug list or 2021 preventive drug list.

Notes about prescription drug coverage: Specialty medications must be purchased from Accredo, Express Scripts’ specialty pharmacy partner. Over-the-counter medications are not covered.