2022 United Stated Benefits Options

Medical Options Summary

Description Deductible

Option 1 HSA Option 2 PPO Option 3 PPO

Single $2,800 Family $5,600 Single $5,100 Family $10,200

Single $1,250 Family $2,500 Single $3,000 Family $6,000 $30/ $75/ $250

Single $500 Family $1,500 Single $2,00 Family $4,000 $25/ $75/ $250

Max out of Pocket

Office Visit/Urgent Care/ Emergency Room

80% coverage after deductible

RX Retail

80% coverage after deductible

$10/$30/$50/$100 $10/$30/$50/$100

Pre-Tax Accounts Available Per Pay Cost Employee only

HSA; FSA Dependent Option 1 HSA

FSA Health; FSA Dependent

FSA Health; FSA Dependent

Option 2 PPO Option 3 PPO

$5.95

$58.09

$78.58

Employee + Spouse

$138.79

$191.52

$241.83

Employee + Child(ren)

$106.59

$147.08

$185.73

Family

$194.93

$268.98

$339.64

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