MEDICAL

Victory Capital Management currently offers three different options for Medical coverage which includes two Qualified High Deductible Health Plans and a Surest Medical Plan through United Healthcare. Listed below are the different options and the costs associated with each option. Cost is listed as the Employee cost per biweekly pay.

	Basic HSA Plan	Core HSA Plan	Surest Medical
Employee Only	$29.54	$56.31	$112.62
Employee + Spouse	$129.23	$205.38	$284.77
Employee + Child(ren)	$105.23	$158.31	$223.85
Family	$162.92	$263.08	$380.77

This is an illustration of In-Network benefits only. Please refer to the Certificate of Coverage for details on Non-Network coverage for final confirmation of coverage.

Plan Name	Basic HSA Plan	Core HSA Plan	Surest Medical
Calendar Year Deductible: Single / Family	$4,000/$8,000	$2,000/$4,000	$0
Coinsurance	100%	100%	100%
Maximum Out of Pocket Limit: Single / Family (Includes the deductible)	$6,650/$13,300	$3,600/$7,200	$5,000/$10,000
Preventive Care Services	100% – no deductible	100% – no deductible	Covered in full
Office Visit	100% after deductible	$25/copay after deductible	$15-100 copay
Specialist Office Visit	100% after deductible	$50/copay after deductible	$15-100 copay
Urgent Care Centers	100% after deductible	$75 after deductible	$50 copay
Virtual Visits	100% after deductible	100% after deductible	$15-100 copay
Lab, X-Rays and Diagnostic Lab	100% after deductible	100% after deductible	Complex Imaging: $125 – $775 Routine Diagnostics(Lab, X-Ray): $0 Other Outpatient Services: $125 – $750
Lab, X-Ray and Major Diagnostics (CT, PET, MRI, MRA, etc.)	100% after deductible	100% after deductible
Emergency Medical Care	100% after deductible	$250 after deductible	$500 copay
Inpatient Hospital Services	100% after deductible	100% after deductible	$2,000
Prescription Drugs:	After deductible	After deductible
Retail Prescription Drugs (30 day supply)	$10/$35/$60	$10/$35/$60	Generic – $10-$20 Preferred Brand – $60 Non-Preferred Brand – $90 Specialty 3 Tier $240/$270/$300
Rx Mail Order (90-day supply)	$25/$87.50/$150	$25/$87.50/$150	Generic – $25-$50 Preferred Brand – $150 Non-Preferred Brand – $225 Specialty 3 Tier $240/$270/$300

VCM Employer HSA Contributions	Basic HSA	Core HSA
Employee Only	$2,050	$1,050
Employee + Spouse	$2,550	$1,300
Employee + Child(ren)	$3,050	$1,550
Family	$3,050	$1,550

In addition, employees may choose to make a contribution into the HSA account on a biweekly basis. – Employees may contribute an additional contribution up to the IRS 2025 Limits of: $4,300/single $8,550 Family (those over age 55 are eligible for an additional $1,000 catch-up contribution). The employer contribution is included as part of the IRS annual limit therefore you should factor in the applicable employer contribution when determining your eligible 2025 contribution. Please consult your tax advisor for additional details.