| HSA Plus | HSA Basic | PPO | ||||||
|---|---|---|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | |||
| Contributions to Your Health Savings Account:* | ||||||||
| Individual | Transocean contributes $400 | Transocean Contributes $150 | N/A | |||||
| You can contribute up to $4,000 | You can contribute up to $4,250 | |||||||
| Family | Transocean contributes $800 | Transocean contributes $300 | N/A | |||||
| You can contribute up to $7,950 | You can contribute up to $8,450 | |||||||
| Deductible: You pay up to this amount before coinsurance. | ||||||||
| Individual | $1,750 | $3,500 | $3,400 | $5,600 | $800 | $1,600 | ||
| Family | $3,500 | $7,000 | $5,600** | $11,200** | $1,600 | $3,200 | ||
| Coinsurance***: After you meet the deductible, Transocean pays the majority of the cost. | ||||||||
| Transocean pays: | 90% | 60% | 80% | 60% | 80% | 60% | ||
| Out-of-Pocket Maximum (includes deductible and medical/Rx copays): After you meet the out-of-pocket maximum, Transocean pays 100%. | ||||||||
| Individual | $3,500 | $7,000 | $5,000 | $10,000 | $5,000 | $10,000 | ||
| Family | $6,850 | $14,000 | $10,000** | $20,000** | $10,000 | $20,000 | ||
| Preventive Care: Annual physicals, screenings, immunizations, etc. | ||||||||
| Transocean covers: | 100% | 60% after deductible | 100% | 60% after deductible | 100% | 60% after deductible | ||
| Medical Services: | ||||||||
| Virtual Visits | $49 max before deductible and 90% after deductible | N/A | $49 max before deductible and 80% after deductible | N/A | $15 copay | N/A | ||
| PCP Office Visit | 90% after deductible | 60% after deductible | 80% after deductible | 60% after deductible | $40 copay | 60% after deductible | ||
| Specialist | $50 copay | |||||||
| Urgent Care | 90% after in-network deductible | 80% after in-network deductible | 80% after deductible | |||||
| Hospital Inpatient & Outpatient | 90% after deductible | 60% after deductible | 80% after deductible | 60% after deductible | 80% after deductible | 60% after deductible | ||
| Emergency Room | 90% after in-network deductible | 80% after in-network deductible | 80% after deductible | |||||
| Prescription Drugs:**** | ||||||||
| Retail (0–30 days) | ||||||||
| Preventive | 100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.) | 100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.) | Covered the same as any other prescription drug | |||||
| Tier 1 | 90% after deductible | 80% after deductible | $15 copay | |||||
| Tier 2 | 70% ($30 min/$100 max) | |||||||
| Tier 3 | 50% ($50 min/$200 max) | |||||||
| Mail (31–60 days) | ||||||||
| Preventive | 100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.) | 100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.) | Covered the same as any other prescription drug | |||||
| Tier 1 | 90% after deductible | 80% after deductible | $15 copay | |||||
| Tier 2 | 70% ($60 min/$200 max) | |||||||
| Tier 3 | 50% ($100 min/$400 max) | |||||||
| Mail (61–90 days) | ||||||||
| Preventive | 100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.) | 100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.) | Covered the same as any other prescription drug | |||||
| Tier 1 | 90% after deductible | 80% after deductible | $30 copay | |||||
| Tier 2 | 70% ($60 min/$250 max) | |||||||
| Tier 3 | 50% ($100 min/$400 max) | |||||||
*If you are over age 55, you can contribute an additional $1,000 in catch-up contributions each year. **Includes embedded deductible and out-of-pocket maximum at the Individual level. ***Coinsurance is the amount that the employee owes after the deductible has been met. This chart reflects Transocean’s portion of the coinsurance amount. ****All prescription drugs must be FDA approved to be covered. If a generic drug is available and you elect to purchase the brand-name drug instead, you will pay the difference between the generic and brand-name drug cost. If your doctor prescribes a brand-name drug, or if no generic is available, brand-name prescription drug will be paid per the plan. For some conditions, you may be required to try an equivalent but lower-cost drug first. PPO only: Prescription drug costs apply to out-of-pocket maximum, not deductible. | ||||||||