HSA PPO

With the HSA PPO plan, you receive full coverage for in-network preventive care and have the same UnitedHealthcare (UHC) Choice Plus network of doctors as the Traditional PPO plan. If you reside in Maine, Massachusetts or New Hampshire you have access to both the Choice Plus network and UHC’s broader Harvard Pilgrim network. There are no co-pays and you must meet the annual deductible before the plan begins to pay benefits. Prescription drugs are part of your deductible. Visit the Pharmacy page for more information.

You may enroll in a Health Savings Account (HSA) which comes with quarterly employer funding. You can use your HSA to cover your out-of-pocket costs including the annual deductible and coinsurance. For HSA eligibility, please refer to the Health Savings Account (HSA) page.

You may also enroll in a Limited Purpose Flexible Spending Account (LPFSA) for your out-of-pocket dental and vision expenses.

The HSA PPO plan gives you the option to visit any provider, allowing you to shop around when you need healthcare. You can visit any doctor or facility, but you will receive the best value when you go in-network. To find in-network providers, visit UHC’s website.

HSA PPO Plan Details

In-Network1 Out-of-Network1
VMware Funding per Quarter2 Individual: $187.50
Family: $375
Individual: $187.50
Family: $375
Annual Deductible Individual: $1,500
Family: $3,000
Individual: $1,500
Family: $3,000
Annual Out-of-Pocket (OOP) Maximum3 Individual: $2,500
Family: $5,000
Individual: $6,000
Family: $12,000
Employee Coinsurance 10% after deductible 30% of UCR4, after deductible
Preventive (Annual Physicals, Well Care Exams) 100% covered, not subject to deductible 30% of UCR4, after deductible
Physician Visits 10% after deductible 30% of UCR4, after deductible
Lab and X-Ray 10% after deductible 30% of UCR4, after deductible
Emergency Room5 10% after deductible 10% after deductible
Ambulance 10% after deductible 10% after deductible
Hospitalization 10% after deductible 30% of UCR4, after deductible
Chiropractic Care 10% after deductible
Up to 20 visits/year
30% after deductible
Up to 20 visits/year
Acupuncture 10% after deductible
Up to 20 visits/year
30% after deductible
Up to 20 visits/year
Massage 10% after deductible
Up to 20 visits/year
10% after deductible
Up to 20 visits/year
Speech Therapy5 10% after deductible 30% after deductible 
Infertility/Fertility Preservation6 10% after deductible
2 Smart Cycles per lifetime
Not Covered

1 Individual deductible and OOP maximum only apply to employees enrolled in Individual tier. Members in dependent tiers must satisfy an aggregate deductible – the health plan doesn’t begin paying benefits until the entire family deductible has been met. Once the entirety of the family deductible has been met, by one family member or a combination of family members, then the cost sharing begins. Paid Interns are only eligible to enroll in the HSA PPO plan.
2 All existing employees enrolled in the HSA PPO as of January 1, 2019 will receive employer funding of $750/$1,500 (Employee Only/Family). All new hires as of January 1, 2019 will receive employer funding on a quarterly basis (divided by 4). VMware funding based on coverage at the end of each quarter. Must be active on the last day of the quarter. Paid Interns are not eligible for VMware funding. HealthEquity accounts funded the pay period following the close of quarter.
3 OOP maximum includes Prescription Rx.
4 Usual, customary and reasonable charges.
5 Available to those with conditions of medical necessity.
6 Benefits provided through Progyny.

Employee Contributions for 2019

Per Paycheck1

Plan Employee Only Employee +
Spouse/Domestic Partner
Employee + Child(ren) Employee + Family
HSA PPO $0 $54.02 $38.90 $97.24

1 Per paycheck contributions are 24 times per year. Contributions are pre-tax (except for Domestic Partner coverage).

Dependent Eligibility

  • Your spouse or domestic partner. Please note: after tax contributions and imputed income may apply when covering a domestic partner. See the Domestic Partner Imputed Income Rate Table for details
  • Your child(ren), your spouse’s / domestic partner’s child(ren), your foster child(ren), the minor(s) you have legal guardianship of are eligible for medical coverage until age 26, regardless of marital or student status.

For more details, see the UHC HSA PPO Summary of Benefits and Coverage (SBC). Residences of Maine, Massachusetts or New Hampshire see the UHC HSA PPO Harvard Pilgrim Summary of Benefits and Coverage (SBC).

Contact Us

HR Source
ASK HR [VMware network access required]
Phone: 1-888-VMWARE8, option ‘US Benefits’
Internal Phone: ext. 29200


Progyny
Phone: 1-833-851-2238
Email: info@progyny.com
Visit website


UnitedHealthcare
Phone: 1-844-562-6290
Visit pre-member website
Visit website

Resources

Benefit Byte Video: Benefits for Living


Benefit Byte Video: Health FSA Plans


Benefit Byte Video: Which Plan is Best for Me: HSA PPO vs Traditional PPO


Benefits Contact Quick Reference Guide


Domestic Partner Imputed Income Rate Table


Key Benefit Terms


Palo Alto Medical Foundation Mobile Clinic


Progyny Fertility Benefits
Overview


Progyny Fertility Benefits for LGBTQIA Members


Progyny Fertility Educational Info


UHC Behavioral Health TOC
Letter


UHC Gender Dysphoria Hair Removal & Voice Therapy Claim Form


UHC Harvard Pilgrim Passport Connect FAQ


UHC Health4Me Mobile App


UHC HealthSafe ID (HSID) Step by Step Registration


UHC Health Insurance Claim
Form


UHC HSA PPO Benefit Summary


UHC HSA PPO Harvard Pilgrim Summary of Benefits and Coverage (SBC)


UHC HSA PPO Summary of Benefits and Coverage (SBC)


UHC HSA PPO Summary Plan Description (SPD)


UHC Massage Therapy Claim
Form


UHC Preventive Care Guidelines


UHC Preventive Care Services with Codes


UHC Rally Health Mobile App


UHC Rally Health Mobile App Webinar


UHC Transtion of Care


UHC Virtual Visits FAQ


Workday [VMware network access required]


Workday Quick Reference Guide: Change HSA Contribution [VMware network access
required
]