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 are eligible to receive quarterly employer funding to your HSA account irrespective of whether you elect to contribute pretax HSA from your paycheck. 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.

If you enroll in an HSA PPO you can only 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 Pay Period²	Individual: $31.25 Family: $62.50	Individual: $31.25 Family: $62.50
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% after deductible
Preventive (Annual Physicals, Well Care Exams)	100% covered, not subject to deductible	30% after deductible
Physician Visits	10% after deductible	30% after deductible
Lab and X-Ray	10% after deductible	30% after deductible
Emergency Room⁴	10% after deductible	10% after deductible
Ambulance	10% after deductible	10% after deductible
Hospitalization	10% after deductible	30% 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 Therapy⁴	10% after deductible	30% after deductible
Infertility/Fertility Preservation	10% after deductible 3 Smart Cycles per lifetime via Progyny	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 will receive the VMware Annual HSA Contribution of $750/$1,500 (Individual/Family). All new hires as of January 1 will receive the employer contributions funded on a per period basis (divided by 24). Paid interns are not eligible for VMware funding.
³ OOP maximum includes Prescription Rx.
⁴ Available to those with conditions of medical necessity.

Employee Contributions for 2023 Per Paycheck¹

Plan	Employee Only	Employee + Spouse/Domestic Partner	Employee + Child(ren)	Employee + Family
HSA PPO	$0	$68.27	$48.04	$123.26

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), and 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).

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Phone: 1-844-562-6290
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Included Health

Formerly Grand Rounds
Included Health is your personal healthcare assistant. Get an expert second opinion at no cost to you. You must be enrolled in a VMware medical plan to use Included Health services. For more information call 1-855-394-1635 or visit includedhealth.com/vmware.