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|
Plans
|
Basic HMO
*Available with Alliance Network |
HNE WisePlus
HDHP HMO M |
HNE WiseMax
HDHP HMO H |
HNE EssentialMax
Option 9H |
HNE Focus *
Option 8H |
| Up-front deductible |
$2,000 per individual
$4,000 per family
per policy OR calendar year |
$2,000 per individual
$4,000 per family
per policy OR calendar year |
$1,000 per individual
$2,000 per family
per policy OR calendar year |
N/A |
| Doctor’s Office |
$0 Preventive Services
$25 after deductible for all other office visits |
$0 Preventive Services
$0 after deductible for all other office visits |
$0 Preventive Services
$20 PCP
$40 Specialist |
$0 Preventive Services
$25 All other office visits |
Emergency
(waived if admitted directly from ER) |
$75 after deductible |
$0 after deductible |
$100 after deductible |
$100 per visit |
Diagnostic Imaging:
CT Scans, MRI, PET Scans |
$0 after deductible |
$0 after deductible |
$100 after deductible |
$150 |
| Outpatient Surgical |
$250 after deductible |
$0 after deductible |
$0 after deductible |
$500 |
| Hospital Stay |
$500 after deductible |
$0 after deductible |
$0 after deductible |
$1,000 |
| Out-of-Pocket Maximum |
$5,000 per individual
$10,000 per family |
$5,000 per individual
$10,000 per family |
$2,000 per individual
$4,000 per family |
$2,000 per individual
$4,000 per family |
| Out-of-Pocket Maximum Includes: |
Deductible and copayments |
Deductible and copayments |
Deductible and services with a copayment of $100 or greater |
Services with a copayment of $100 or greater |
