Page 9 - GXO 2022 OE Guide-Active

How the plans compare
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IN-NETWORK
Deductible
Basic HSA
$2,500
HSA Plus
$1,750
Basic PPO
$1,250
Classic PPO
$900
INDIVIDUAL
Company HSA Contribution
Not Applicable
$500
Not Applicable
Not Applicable
Your HSA Contribution
Up to $3,650
Up to $3,150 ($3,650 IRS limit minus company contribution)
Not Applicable
Not Applicable
Out-of-Pocket Maximum
$5,000
$5,000
$5,000
$5,000
EMPLOYEE + ONE OR MORE
Deductible*
Your HSA Contribution
$5,000
Up to $7,300
$3,500
Up to $6,300 ($7,300 IRS limit minus company contribution)
$2,500
Not Applicable
$1,800
Not Applicable
Company HSA Contribution
Not Applicable
$1,000
Not Applicable
Not Applicable
Out-of-Pocket Maximum*
$10,000
$10,000
$10,000
$10,000
* To learn how one family member can meet the deductible and out-of-pocket maximum for the entire family, review the Medical FAQs under the Resources tab on www.GXOBenefits.com.
What you pay for services
IN-NETWORK
Office Visits
Primary Care Specialist
Hospital, X-Ray and Laboratory
Basic HSA
30% after deductible 30% after deductible
30% after deductible
HSA Plus
20% after deductible 20% after deductible
Basic PPO
$35 copay $55 copay
Classic PPO
$35 copay $55 copay
20% after deductible
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Preventive Care
$0
$0
$0
$0
Emergency Care
30% after deductible
20% after deductible
20% after $150 copay
20% after $150 copay
20% after deductible
20% after deductible
Medical I 7