| 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 |
$400
$800 |
$400
$800 |
N/A
N/A |
N/A
N/A |
Deductible
Employee Only
Family |
$3,400
$6,800 |
$6,800
$13,600 |
$1,800
$3,600 |
$3,600
$7,200 |
$1,000
$1,000 per person, up to $3,000 |
$1,000
$1,000 per person, up to $3,000 |
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 | $0 no deductible
| $0 no deductible
| $0 no deductible
| $0 no deductible
| $0 no deductible
| $0 no deductible
|
| Primary Care Office Visits | 30% after deductible | 45% after deductible | 20% after deductible | 35% after deductible | $45 copay | $45 copay |
| Specialist Office Visits | 30% after deductible | 45% after deductible | 20% after deductible | 35% after deductible | $70 copay | $70 copay |
Outpatient Care
| 30% after deductible | 45% after deductible | 20% after deductible | 35% after deductible | 20% after deductible | 20% after deductible |
Hospital Stays
(Inpatient Care) | 30% after deductible | 45% after deductible | 20% after deductible | 35% after deductible | 20% after $325 copay, no deductible | 20% after $325 copay, no deductible |
| Urgent Care | 30% after deductible | 45% after deductible | 20% after deductible | 35% after deductible | 20% after $70 copay, no deductible | 20% after $70 copay, no deductible |
Emergency
Room | 30% after deductible | 30% after deductible | 20% after deductible | 20% after deductible | 20% after $200 copay, no deductible | 20% after $200 copay, no deductible |