| In-Network | Out‑of‑Network | In-Network | Out‑of‑Network | In-Network Only | In-Network Only |
CareFirst Network | BlueChoice Advantage | BlueChoice Advantage | BlueChoice Advantage | BlueHPN |
Nestlé HSA
Contribution
Employee Only
Family |
$500
$1,000 |
$500
$1,000 |
N/A
N/A |
N/A
N/A |
Deductible
Employee Only
Family |
$3,200
$6,400 |
$6,400
$12,800 |
$1,600
$3,200 |
$3,200
$6,400 |
$750
$750 per person, up to $2,250 |
$750
$750 per person, up to $2,250 |
Out-of-Pocket
Maximum
Employee Only
Family |
$6,000
$6,850 per person, up to $12,000 |
$12,000
12,000 per person, up to $24,000
|
$4,500
$6,850 per person, up to $9,000 |
$9,000
9,000 per person, up to $18,000 |
$3,050
$3,050 per person, up to $6,100 |
$3,050
$3,050 per person, up to $6,100 |
Preventive Care
First $500 in Benefits
After $500 in Benefits |
$0 no deductible
$0 no deductible |
$0 no deductible
45% no deductible |
$0 no deductible
$0 no deductible |
$0 no deductible
35% no deductible |
$0 no deductible
$0 no deductible |
$0 no deductible
$0 no deductible |
Specialists | 25% after deductible | 45% after deductible | 15% after deductible | 35% after deductible | $70 copay | $70 copay |
Primary Care | 25% after deductible | 45% after deductible | 15% after deductible | 35% after deductible | $35 copay | $35 copay |
Outpatient Care
| 25% after deductible | 45% after deductible | 15% after deductible | 35% after deductible | 20% after deductible | 20% after deductible |
Hospital Stays
(Inpatient Care) | 25% after deductible | 45% after deductible | 15% after deductible | 35% after deductible | 20% after $325 copay, no deductible | 20% after $325 copay, no deductible |
Emergency
Room | 25% after deductible | 45% after deductible | 15% after deductible | 35% after deductible | 20% after $200 copay, no deductible | 20% after $200 copay, no deductible |
Urgent Care | 25% after deductible | 45% after deductible | 15% after deductible | 35% after deductible | 20% after $70 copay, no deductible | 20% after $70 copay, no deductible |