Your share of costs in each network
This chart shows how the provider network for each medical plan impacts your out-of-pocket costs, including deductibles (ded), coinsurance (coins) and copays for different services. Preventive care is free in both plans.
For more information about how you and the health system share the cost for your healthcare expenses on either plan, read Understanding deductibles, copays and coinsurance.
HSA Advantage Plan | Signature Plan | |||||
Health system network | In-network* | Out-of-network | ||||
Annual | $1,800 individual $3,600 family | $4,000 individual $8,000 family | $6,400 individual $12,800 family | $500 individual $1,000 family | $2,000 individual $4,000 family | $4,000 individual $8,000 family |
Annual maximum out-of-pocket costs^ | $4,500 individual $9,000 family | $6,000 individual $9,200 family | $19,800 individual $39,600 family | $4,500 individual $9,000 family | $6,000 individual $12,000 family | $10,500 individual $21,000 family |
Member | You pay 10%; | You pay 30%; | You pay 40%; | You pay 10%; | You pay 30%; | You pay 40%; |
At the doctor’s office | ||||||
Routine preventive care | You pay $0; | You pay $0; | 40% coinsurance after deductible | You pay $0; | You pay $0; | 40% coinsurance |
Primary care | 10% coinsurance | 30% coinsurance after deductible | 40% coinsurance after deductible | $20 copay | $30 copay | 40% coinsurance |
Specialist | 10% coinsurance after deductible | 30% coinsurance after deductible | 40% coinsurance after deductible | $40 copay | $60 copay | 40% coinsurance |
Urgent Care | 10% coinsurance | 30% coinsurance after deductible | 40% coinsurance after deductible | $40 copay | $60 copay | 40% coinsurance |
At the hospital | ||||||
Emergency | 10% coinsurance after deductible | 30% coinsurance after deductible | 30% coinsurance after deductible** | 10% coinsurance after deductible | 30% coinsurance after deductible | 30% coinsurance after deductible** |
Inpatient / Outpatient services | 10% coinsurance | 30% coinsurance after deductible | 40% coinsurance after deductible | 10% coinsurance | 30% coinsurance | 40% coinsurance after deductible |
Other medical benefits | ||||||
Outpatient therapy (speech, hearing, PT, OT) | 10% coinsurance after deductible | 30% coinsurance after deductible | 40% coinsurance after deductible | 10% coinsurance after deductible^^^ | 30% coinsurance after deductible | 40% coinsurance |
Mental health & substance use | ||||||
Inpatient | 10% coinsurance after deductible | 30% coinsurance after deductible | 40% coinsurance after deductible | 10% coinsurance after deductible^^^ | 30% coinsurance after deductible^^^ | 40% coinsurance |
Outpatient services^^ | 10% coinsurance | 30% coinsurance after deductible | 40% coinsurance after deductible | $20 copay for office visits; all other services | $30 copay for office visits; 30% coinsurance after deductible for all other services | 40% coinsurance after deductible |
Pharmacy | ||||||
Prescription medication coverage is a big factor in choosing a medical plan. Read the Prescription drug coverage section for important details. | ||||||
*In-network providers are part of either BlueSelect Plus or BlueCard PPO Network. **To ensure access to emergency care, coinsurance for qualified ER visits applied after deductible is met for in-network care. ***Preauthorization required; coverage of room and board may be denied. ^^Preauthorization required for ABA therapy. | ||||||