Medical Plan Summary of Benefits

Comparative Features	High Deductible Health Plan (HDHP) Benefits Covered Employees Elect Either a Companion HSA or HRA
Comparative Features	In-Network	Out-of-Network
Deductible
Individual	$2,500	N/A (In- and out-of-network Deductible cross-accumulate
Family	$5,000	N/A (In- and out-of-network Deductible cross-accumulate
Out-of-Pocket (OOP) Maximum
Individual	$4,000	N/A (In- and out-of-network Deductible cross-accumulate
Family	$8,000
*within Family coverage, Individual Max also applies	$4,000
	The OOP max includes deductible, coinsurance, and any other covered medical expenses
SPU Funding to offset Deductible for HSA Plan	Individual HSA Plan: Up to $1,608, (assuming 12-months of participation and employee meets full dollar-for-dollar match) Family HSA Plan: Up to $3,016 (assuming 12-months of participation and employee meets full dollar-for-dollar match)
SPU Funding to offset Deductible for HRA Plan	Individual HRA Plan: SPU makes $1,008 available for reimbursement Family HRA Plan: SPU makes $2,016 available for reimbursement
Coinsurance - You pay:	10%	40%
Office Visits	No copay; You pay 10% AFTER Deductible	No copay; You pay 40% AFTER Deductible
Preventive Care – Routine Physicals (Adult exams) Routine Well-Child Exams Routine Mammograms Routine DRE/Prostate Antigen Test/Exam for males Routine Colorectal Cancer Screening	Covered 100%; deductible waived Diagnostic mammograms covered under Diagnostic Lab/X-ray
In-Network Diagnostic Lab/X-ray Outpatient	No copay; You pay 10% AFTER Deductible	No copay; You pay 40% AFTER Deductible
Urgent Care Provider (both In and Out-of-Network)	No copay; You pay 10% AFTER Deductible
Emergency Room (both In and Out-of-Network)	No copay; You pay 10% AFTER Deductible
Ambulance (both In and Out-of-Network)	No copay; You pay 10% AFTER Deductible
Hospital - Inpatient (both In and Out-of-Network)	No copay; You pay 10% AFTER Deductible
Prescription Drugs
In-Network - Pharmacy – Retail	10% (generic) /20% (preferred brand)/30% (non-preferred brand) AFTER Deductible Full cost of prescriptions accumulate towards the deductible Specific Generic Preventive drugs covered at 100% with deductible waived Other Brand-Name Preventive drugs require you pay 20% or 30% with deductible waived	Not covered
Pharmacy – Mail Order Drug (90 day supply)	10% (generic) /20% (preferred brand) /30% non-preferred brand) AFTER Deductible Full cost of prescriptions accumulate towards the deductible Specific Generic Preventive drugs covered at 100%, deductible waived Other Brand-Name Preventive drugs require you pay 20% or 30% with deductible waived Shop pharmacies for lowest price	Not covered