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Duckett Creek Sanitary District
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Health Savings Account (HSA) - BASE
Anthem H.S.A. Plan Summary
(PPO - Blue Access Choice 5-Z)
Type of
Coverage
Employee
Bi-Monthly Cost
Employee
$0
Employee & Spouse
$91.39
Employee & Child(ren)
$78.93
Employee & Family
$170.32
For those participating in the Qualified High Deductible Health Plan, Duckett Creek will
contribute $2,000 for individual coverage and $4,000 for those with dependents. These
contributions will be made once per quarter; $500 for individual and $1,000 for those
covering dependents.
Benefit/Service
In-Network
Out-of-Network
Deductible
(single / family)
$2,000/$4,000
(non-embedded)
$2,000/$4,000
(non-embedded)
Coinsurance
100%
70%
Out of Pocket Max.
(single/family)
$3,000/$6,000
$6,000/$12,000
Inpatient Hospital
100% after Ded.
70% after Ded.
Outpatient Hospital
100% after Ded.
70% after Ded.
Office Visit Copay
(PCP /Specialist)
100% after Ded.
70% after Ded.
Emergency Room
100% after Ded.
70% after Ded.
Urgent Care
100% after Ded.
70% after Ded.
Prescription
Retail
Mail Order
After Ded:
$10/$30/$50/25%
$10/$75/$150/25%
50% with a minimum
of $45
N/A
Lifetime Max Benefit
Unlimited
Unlimited