| 2021 | BASIC HSA | HSA PLUS | BASIC PPO | CLASSIC 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 applicable | Not 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 Formulary | 30% 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-Formulary | 50% 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) |
Notes about prescription drug coverage: Specialty medications must be purchased from Accredo, Express Scripts’ specialty pharmacy partner. Over-the-counter medications are not covered.
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