Sample Benefit Enrollment Guide

Company Name

Medical Plan Summary

Medical Plan Designs

HSA PPO

PPO Plan

In Network Benefits

Funding of HSA

$X

$X

Deductible

$X

$X

Insurance coverage when deductible is reached (coinsurance)

$X

$X

Your cost for primary Dr.

$X

$X

Your cost for specialist

$X

$X

Emergency/Urgent Care

$X

$X

Inpatient Hospital

$X

$X

Preventive Care

$X

$X

Out-of-Pocket Maximum

$X

$X

Out of Network Benefits

Deductible

$X

$X

Coinsurance

$X

$X

Out-of-Pocket

$X

$X

* NOTE: The full cost of what you pay a provider may not necessarily be credited/counted towards your out-of-network deductible. The insurance company will only count the cost deemed reasonable and customary by them for that service.

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