Page 8 - CPSS Benefit Guide Class 3 Employee
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Out-of-Pocket Plan Comparison
The tables below show examples of what you may expect to pay annually for each of our medical
plans. Please note that the prices in the HSA plan are illustrative while the prices in the PPO plan
are based on copayments. Since you pay 100% of costs until you hit your deductible with the
HSA (excluding preventive services), estimations are needed for examples such as these.
Another important note is that the HSA plan has a line for -$800 towards your annual spend. This
is due to the HSA employer contribution that CPS&S gives to those who elect this plan.
Employee Only Family
Service $1,500 PPO $2,300 HSA Service $1,500 PPO $2,300 HSA
Employee Annual $1,160 $762 Employee Annual $5,840 $4,763
Premiums Premiums
Primary Care Office $30 $50 Primary Care Office $120 $200
Visits (1) Visits (4)
Specialist Visit (1) $50 $75 Specialist Visit (3) $150 $225
Minor Lab Service (1) $25 $40 Minor Lab Service (1) $25 $40
Annual Preventive $0 $0 Annual Preventive $0 $0
Care (1) Care (4)
Tier 1 Prescription (1) $120 $240 Tier 1 Prescription (4) $480 $960
Remaining Deductible $1,275 $1,875 Remaining Deductible $2,275 $3,830
Additional towards $500 $500 Additional towards $500 $500
Coinsurance Coinsurance
Employer HSA N/A ($800) Employer HSA N/A ($800)
Contribution Contribution
Employee Grand Total $3,160 $2,742 Employee Grand Total $9,390 $9,718
* Note that these are only examples and actual copays, and
amounts will vary
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