Intermediary Groups: Premium HMO

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Intermediary Groups: 1-5 Eligible Employees
 Plans

Premium HMO

*Available with Alliance Network

HNE Principle *
Option 4
HNE Health
Up-front deductible N/A N/A
Doctor’s Office

$0 Preventive Services

$15

$0 Preventive Services

$15 PCP

$25 Specialist

Emergency
(waived if admitted directly from ER)
$50 per visit $75 per visit
Diagnostic Imaging:
CT Scans, MRI, PET Scans
$0 $0
Outpatient Surgical $150 $100
Hospital Stay $250 $100
Out-of-Pocket Maximum $500 per individual

$1,000 per family

$500 per individual

$1,000 per family

Out-of-Pocket Maximum Includes: Services with copayment of $150 or greater Services with copayment of $100 or greater