HANCOCK COMMUNITY HEALTH PLAN

HSA 5000

HSA 5000 Plan: Flexible, Tax-Advantaged Coverage Ideal for Employers who want to offer employees control over their healthcare spending with the added benefit of tax savings.

Features:

$5,000 Individual / $10,000 Family Deductible: Higher deductible offset by lower premiums and the ability to save pre-tax dollars in an HSA.
HSA-Compatible: Employees and employers can contribute to a Health Savings Account, giving employees more control over their healthcare dollars.
0% Coinsurance (After Deductible): Direct Primary Care, Advanced Imaging (CT/MRI/PET), Hospital Stays, Outpatient Procedures, and Childbirth/Delivery remain fully covered at no cost.

Benefits:

Tax Savings: Contributions to HSAs are tax-deductible, and funds grow tax-free when used for qualified medical expenses.
Employee Empowerment: Employees gain ownership over their healthcare spending while still having access to no-cost core services.
Lower Premiums: Employers can reduce premium costs while offering a plan that appeals to employees who prefer saving for future healthcare expenses.
Community-Focused Care: Built around Hancock Health, ensuring employees receive high-quality, local healthcare..

PLAN DETAILS

SERVICE	TIER 1 Hancock Health or Preferred Network	TIER 2 PHCS for VDHP or Participating Providers	TIER 3 Non-Participating Providers	LIMITS / INFO
Deductible (Individual / Family)	$5,000 /$15,000	$5,000 /$15,000	$5,000 /$15,000	N/A
Out of Pocket Max (Individual / Family)	$5,000 /$15,000	$5,000 /$15,000	$10,000 / $20,000	N/A

PHYSICIAN SERVICES

SERVICE	PARTICIPATING PROVDERS	NON-PARTICIPATING PROVIDERS	LIMITS / INFO
Preventative Care*	$0	$0	As Outlined by the Affordable Care Act
Primary Care Visit	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	N/A
Specialist Care Visit	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	Preauthorization Required
Chiropractic Services	0% Coinsurance (After Deductible)	50% Coinsurance	Limited to 12 Visits Per Plan Year
Physical Rehabilitation	0% Coinsurance (After Deductible)	50% Coinsurance	Preauthorization Required. Limited to 12 Visits Per Plan Year.
Mental Health Outpatient	0% Coinsurance (After Deductible)	50% Coinsurance	Preauthorization Required
Mental Health Inpatient	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	Preauthorization Required
Urgent Care	0% Coinsurance (After Deductible)	50% Coinsurance	N/A

*Routine Adult & Child Care | Immunizations | Cancer Screenings | Mammograms | OB/GYN Visits

HOSPITAL SERVICES

SERVICE	TIER 1 Hancock Health or Preferred Network	TIER 2 PHCS for VDHP or Participating Providers	TIER 3 Non-Participating Providers	LIMITS / INFO
Diagnostic Test (X-Ray / Blood Work)	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	50% Coinsurance	Preauthorization Required
Advanced Imaging (CT / MRI / PET)	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	50% Coinsurance	Preauthorization Required
Emergency Room	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	N/A
Ambulance	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	N/A
Hospital Stay And Outpatient Procedures	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	Preauthorization Required
Childbirth / Delivery Services	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	0% Coinsurance (After Deductible)	Preauthorization Required

PRESCRIPTIONS

30/90 Day

Generics, Formulary and Non-Formulary Barans: 0% Coinsurance (After Deductible)

Specialty: Contact Care Coordination

Non-Formulary Brand: $75 / $150 Copay

Specialty: Contact Care Coordination

Rx 30-Day Supply is Retail Only, 90-Day Supply is Retail or Mail Order. Please See the Plan Documents for Complete Coverage Details, Limits, and Exclusions.

HANCOCK COMMUNITY HEALTH PLAN