What You Pay in the HSA Plan

In-Network Out-of-Network
Sysco’s Contribution to Your Health Savings Account $250 You Only
$500 All other coverage levels
Deductible* $2,000 Individual
$4,000 Family
$4,000 Individual
$8,000 Family
Coinsurance Plan pays 90% after deductible
You pay 10% after deductible
Plan pays 65% after deductible
You pay 35% after deductible
Out-of-Pocket Maximum $5,500 Individual
$12,000 Family
$10,000 Individual
$30,000 Family
Preventive Care Covered at 100% (no deductible) You meet your deductible, then pay 35% coinsurance.
Telehealth $4 copay after deductible, up to a maximum $44 allowance 35% coinsurance after deductible
Primary Care Office Visit You meet your deductible, then pay 10% coinsurance. You meet your deductible, then pay 35% coinsurance.
Specialist Office Visit
Urgent Care
Emergency Room
Hospitalization
Lab, X-Ray, Imaging You meet your deductible, then pay 10% coinsurance. You meet your deductible, then pay 35% coinsurance.
Mental Health Available through Optum. See the Mental Health section for more information.
Prescription Drugs** – You meet your deductible, then pay applicable copays or coinsurance.
Pharmacy-Filled Generic
(30-day supply)
$12 copay after deductible You meet your deductible, then pay 50% coinsurance ($50 minimum) of the reasonable and customary charges.
Pharmacy-Filled Formulary
(30-day supply)
30% after deductible
($40 min. / $80 max.)
Pharmacy-Filled Non-formulary
(30-day supply)
50% after deductible
($80 min. / $160 max.)
Mail Ordered Generic
(90-day supply)
$30 copay after deductible N/A
Mail Ordered Formulary
(90-day supply)
30% after deductible
($80 min / $160 max.)
Mail Ordered Non-formulary
(90-day supply)
50% after deductible
($180 min / $350 max.)