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What you pay for medical services
| 2024 | HSA 5000 | HSA 2000 | PPO 1500 | PPO 750 | Kaiser HMO (California only) |
|---|---|---|---|---|---|
| GXO HSA Contribution | Individual: Up to $500 Employee + One or More: Up to $1,000 | Individual: Up to $500 Employee + One or More: Up to $1,000 | PPO 1500 does not include an HSA. | PPO 750 does not include an HSA. | Kaiser HMO does not include an HSA. |
| Annual Deductible (Employee Only) | In-Network: $5,000 Out-of-Network: $10,000 | In-Network: $2,000 Out-of-Network: $4,000 | In-Network: $1,500 Out-of-Network: $3,000 | In-Network: $750 Out-of-Network: $1,500 | In-Network: $1,500 Out-of-Network: Not covered. |
| Annual Deductible (Employee + Spouse or Employee + Child) | In-Network: $10,000 Out-of-Network: $20,000 | In-Network: $4,000 Out-of-Network: $8,000 | In-Network: $3,000 Out-of-Network: $6,000 | In-Network: $1,500 Out-of-Network: $3,000 | In-Network: $3,000 Out-of-Network: Not covered. |
| Annual Deductible (Employee + Children or Employee + Family) | In-Network: $10,000 Out-of-Network: $20,000 | In-Network: $4,000 Out-of-Network: $8,000 | In-Network: $4,500 Out-of-Network: $9,000 | In-Network: $2,250 Out-of-Network: $4,500 | In-Network: $3,000 Out-of-Network: Not covered. |
| Coinsurance (after you meet the deductible) | In-Network: You Pay: 30% GXO Pays: 70% Out-of-Network: You Pay: 50% GXO Pays: 50% | In-Network: You Pay: 20% GXO Pays: 80% Out-of-Network: You Pay: 50% GXO Pays: 50% | In-Network: You Pay: 20% GXO Pays: 80% Out-of-Network: You Pay: 50% GXO Pays: 50% | In-Network: You Pay: 20% GXO Pays: 80% Out-of-Network: You Pay: 50% GXO Pays: 50% | In-Network: You Pay: 20% GXO Pays: 80% Out-of-Network: Not covered. |
| Annual Out-of-Pocket Maximum (Employee Only) | In-Network: $7,500 Out-of-Network: $15,000 | In-Network: $5,000 Out-of-Network: $10,000 | In-Network: $5,000 Out-of-Network: $10,000 | In-Network: $3,000 Out-of-Network: $10,000 | In-Network: $4,000 Out-of-Network: Not covered. |
| Annual Out-of-Pocket Maximum (Employee + Spouse or Employee + Child) | In-Network: $15,000 Out-of-Network: $30,000 | In-Network: $10,000 Out-of-Network: $20,000 | In-Network: $10,000 Out-of-Network: $20,000 | In-Network: $6,000 Out-of-Network: $20,000 | In-Network: $8,000 Out-of-Network: Not covered. |
| Annual Out-of-Pocket Maximum (Employee + Children or Employee + Family) | In-Network: $15,000 Out-of-Network: $30,000 | In-Network: $10,000 Out-of-Network: $20,000 | In-Network: $15,000 Out-of-Network: $30,000 | In-Network: $9,000 Out-of-Network: $30,000 | In-Network: $8,000 Out-of-Network: Not covered. |
| Preventive Care | In-Network: No copay. GXO pays 100% of the cost. Out-of-Network: Not covered. | In-Network: No copay. GXO pays 100% of the cost. Out-of-Network: Not covered. | In-Network: No copay. GXO pays 100% of the cost. Out-of-Network: Not covered. | In-Network: No copay. GXO pays 100% of the cost. Out-of-Network: Not covered. | In-Network: No copay. GXO pays 100% of the cost. Out-of-Network: Not covered. |
| Primary Care Physician | No copay. Coinsurance applies. | No copay. Coinsurance applies. | In-Network: $30 copay Out-of-Network: No copay. Coinsurance applies. | In-Network: $20 copay Out-of-Network: No copay. Coinsurance applies. | In-Network: $20 copay Out-of-Network: Not covered. |
| Specialist | No copay. Coinsurance applies. | No copay. Coinsurance applies. | In-Network: $60 copay Out-of-Network: No copay. Coinsurance applies. | In-Network: $40 copay Out-of-Network: No copay. Coinsurance applies. | In-Network: $20 copay Out-of-Network: Not covered. |
| Behavioral Health | No copay. Coinsurance applies. | No copay. Coinsurance applies. | In-Network: $30 copay Out-of-Network: No copay. Coinsurance applies. | In-Network: $20 copay Out-of-Network: No copay. Coinsurance applies. | In-Network: $20 copay Out-of-Network: Not covered. |
| Telehealth | In-Network: 30% after deductible Out-of-Network: Not covered. | In-Network: 20% after deductible Out-of-Network: Not covered. | In-Network: $10 copay Out-of-Network: Not covered. | In-Network: $10 copay Out-of-Network: Not covered. | In-Network: No copay. GXO pays 100% of the cost. Out-of-Network: Not covered. |
| Urgent Care (facility only) | No copay. Coinsurance applies. | No copay. Coinsurance applies. | $60 copay | $60 copay | In-Network: $20 copay Out-of-Network: $20 copay |
| Emergency Room (facility only) | No copay. Coinsurance applies. | No copay. Coinsurance applies. | $150 copay. Coinsurance applies. | $150 copay. Coinsurance applies. | No copay. Coinsurance applies. |
| Inpatient Hospital (includes behavioral health) | No copay. Coinsurance applies. | No copay. Coinsurance applies. | No copay. Coinsurance applies. | No copay. Coinsurance applies. | No copay. Coinsurance applies. |
| Physician Services (inpatient/outpatient) | No copay. Coinsurance applies. | No copay. Coinsurance applies. | No copay. Coinsurance applies. | No copay. Coinsurance applies. | No copay. Coinsurance applies. |
A note about meeting the family deductible and out-of-pocket maximum: To learn how one family member can meet the deductible and out-of-pocket maximum for the entire family, review the Medical FAQs.
A note about Anthem out-of-network expenses: Out-of-network expenses are limited to the eligible maximum allowed amount. You are responsible for paying any amount over the eligible maximum allowed amount charges in addition to your deductible and coinsurance.
A note about Kaiser HMO out-of-network coverage: Kaiser will only cover out-of-network urgent care or emergency care. You are responsible for all other out-of-network expenses.
