CDHP/HSA Plan
CDHP/HSA Plan
CDHP/HSA Plan
Plan Details
Carrier
United Healthcare
Network
United Healthcare Choice Plus
Plan Type
CDHP/HSA
HSA Eligible
Yes
FSA Eligible
Dependent Care FSA
Premiums
| Coverage Tier | CDHP/HSA Plan — Wellness | CDHP/HSA Plan — Non-Wellness |
|---|---|---|
| Employee Only | $58.52 | $71.02 |
| Employee + Spouse | $158.34 | $170.84 |
| Employee + Child(ren) | $127.10 | $139.60 |
| Employee + Family | $285.64 | $298.14 |
Employee Only
- CDHP/HSA Plan — Wellness
- $58.52
- CDHP/HSA Plan — Non-Wellness
- $71.02
Employee + Spouse
- CDHP/HSA Plan — Wellness
- $158.34
- CDHP/HSA Plan — Non-Wellness
- $170.84
Employee + Child(ren)
- CDHP/HSA Plan — Wellness
- $127.10
- CDHP/HSA Plan — Non-Wellness
- $139.60
Employee + Family
- CDHP/HSA Plan — Wellness
- $285.64
- CDHP/HSA Plan — Non-Wellness
- $298.14
Deductible, Out-of-Pocket & Coinsurance
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Individual | $3,400 | $6,000 |
| Family | $6,000 | $12,000 |
| Coinsurance (You Pay) | 20%* | 50%* |
| Calendar Year Out-Of-Pocket Maximum (Maximum Includes Deductible) - Individual | $5,000 | $10,000 |
| Calendar Year Out-Of-Pocket Maximum (Maximum Includes Deductible) - Family | $10,000 | $20,000 |
Individual
- In-Network
- $3,400
- Out-of-Network
- $6,000
Family
- In-Network
- $6,000
- Out-of-Network
- $12,000
Coinsurance (You Pay)
- In-Network
- 20%*
- Out-of-Network
- 50%*
Calendar Year Out-Of-Pocket Maximum (Maximum Includes Deductible) - Individual
- In-Network
- $5,000
- Out-of-Network
- $10,000
Calendar Year Out-Of-Pocket Maximum (Maximum Includes Deductible) - Family
- In-Network
- $10,000
- Out-of-Network
- $20,000
- *After deductible
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | No charge | 50%* |
| Primary Care | 20%* | 50%* |
| Specialist Services | 20%* | 50%* |
| Virtual Visits | $49 fee | N/A |
| Urgent Care | 20%* | 50%* |
| Diagnostic Tests | 0%* | 50%* |
| Inpatient Care | 20%* | 50%* |
| Outpatient Facility | 20%* | 50%* |
| Emergency Room | 20%* | 20%* |
Preventive Care
- In-Network
- No charge
- Out-of-Network
- 50%*
Primary Care
- In-Network
- 20%*
- Out-of-Network
- 50%*
Specialist Services
- In-Network
- 20%*
- Out-of-Network
- 50%*
Virtual Visits
- In-Network
- $49 fee
- Out-of-Network
- N/A
Urgent Care
- In-Network
- 20%*
- Out-of-Network
- 50%*
Diagnostic Tests
- In-Network
- 0%*
- Out-of-Network
- 50%*
Inpatient Care
- In-Network
- 20%*
- Out-of-Network
- 50%*
Outpatient Facility
- In-Network
- 20%*
- Out-of-Network
- 50%*
Emergency Room
- In-Network
- 20%*
- Out-of-Network
- 20%*
Pharmacy Benefits
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Rx Deductible | N/A | N/A |
| Retail Rx (Up To 30-Day Supply) | ||
| Generic | 20%* | 20%* |
| Preferred Brand | 20%* | 20%* |
| Non-Preferred Brand | 20%* | 20%* |
| Mail Order Rx (Up To 90-Day Supply) | ||
| Generic | 20%* | Not covered |
| Preferred Brand | 20%* | Not covered |
| Non-Preferred Brand | 20%* | Not covered |
Rx Deductible
- In-Network
- N/A
- Out-of-Network
- N/A
Retail Rx (Up To 30-Day Supply)
- In-Network
- Out-of-Network
Generic
- In-Network
- 20%*
- Out-of-Network
- 20%*
Preferred Brand
- In-Network
- 20%*
- Out-of-Network
- 20%*
Non-Preferred Brand
- In-Network
- 20%*
- Out-of-Network
- 20%*
Mail Order Rx (Up To 90-Day Supply)
- In-Network
- Out-of-Network
Generic
- In-Network
- 20%*
- Out-of-Network
- Not covered
Preferred Brand
- In-Network
- 20%*
- Out-of-Network
- Not covered
Non-Preferred Brand
- In-Network
- 20%*
- Out-of-Network
- Not covered
- *After deductible
Plan Notes
- You'll pay less in premiums. (Think less money from your paycheck.)
- You'll pay for the full cost of non-preventive medical services until you reach your deductible.
- You can also use a Health Savings Account in conjunction, which provides a safety net for unexpected medical costs and tax advantages.
- If you expect to mostly use preventive care (which is covered), this plan could be for you.