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| Large Groups: 51+ Eligible Employees |
| Plans |
Preferred Provider Organization (PPO) |
HNE PPO Wise
HDHP PPO H |
HNE PPO Complete |
HNE PPO Complete National |
| In-Plan |
Out-of-Plan |
In-Plan
|
Out-of-Plan |
In-Plan
|
Out-of-Plan |
| Up-front deductible |
$2,000 per individual
$4,000 per family |
$2,000 per individual
$4,000 per family |
N/A |
$1,000 per individual
$2,000 per family
per calendar year |
N/A |
$1,000 individual
$2,000 family
per calendar year |
| Doctor’s Office |
$0 Preventive Services
$0 after deductible for all other office visits |
20% after deductible |
$0 Preventive Services
$20 |
20% after deductible |
$0 Preventive Services
$30 per visit |
20% after deductible |
Emergency
(waived if admitted directly from ER) |
$0 after deductible |
20% after deductible |
$50 per visit |
$50 per visit |
$50 per visit |
$50 per visit |
Diagnostic Imaging:
CT Scans, MRI, PET Scans |
$0 after deductible |
20% after deductible |
$0 |
20% after deductible |
$0 |
20% after deductible |
| Outpatient Surgical |
$0 after deductible |
20% after deductible |
$250 |
20% after deductible |
$250 |
20% after deductible |
| Hospital Stay |
$0 after deductible |
20% after deductible |
$500 |
20% after deductible |
$500 |
20% after deductible |
| Out-of-Pocket Maximum |
$5,000 per individual
$10,000 per family |
$7,500 per individual
$15,000 per family |
$1,000 per individual
$2,000 per family
|
$3,000 per individual
$6,000 per family
|
$1,000 per individual
$2,000 per family |
$3,000 per individual
$6,000 per family
|
| Out-of-Pocket Maximum Includes: |
Deductible and copayments |
Deductible and 20% coinsurance |
Services with a copayment of $250 or greater |
Deductible and 20% coinsurance |
Services with a copayment of $250 or greater |
Deductible and 20% coinsurance |
| Prescription Drugs |
|
