HSA Qualified Plan PPO Plan Rx Deductible Integrated w/ Medical Plan N/A Single / Family Rx Out-of-Pocket Max Integrated w/ Medical Plan $1,725 / $3,450 Retail Prescriptions: Generic 20% after deductible 20% coinsurance ($7 min / $25 max) Retail Prescriptions: Preferred 40% after deductible 40% coinsurance ($35 min) Retail Prescriptions: Non-Preferred 50% after deductible 50% coinsurance ($60 min) Retail Prescriptions: Specialty $110 copay after deductible $110 copay Mail Order Prescriptions: Generic 20% after deductible 20% coinsurance ($15 min / $65 max) Mail Order Prescriptions: Preferred 40% after deductible 40% coinsurance ($70 min / $110 max) Mail Order Prescriptions: Non-Preferred 50% after deductible 50% coinsurance ($120 min / $160 max)