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| Intermediary Groups: 1-5 Eligible Employees |
| Plans |
Preferred Provider Organization (PPO) |
| HNE PPO Focus |
HNE PPO Complete |
| In-Plan |
Out-of-Plan |
In-Plan |
Out-of-Plan |
| Up-front deductible |
N/A |
$1,000 per individual
$2,000 per family
per calendar year |
N/A |
$1,000 per individual
$2,000 per family
per calendar year |
| Doctor’s Office |
$0 Preventive Services
$25 |
20% after deductible |
$0 Preventive Services
$20 |
20% after deductible |
Emergency
(waived if admitted directly from ER) |
$100 per visit |
$100 per visit |
$50 per visit |
$50 per visit |
Diagnostic Imaging:
CT Scans, MRI, PET Scans |
$100 per visit |
20% after deductible |
$0 |
20% after deductible |
| Outpatient Surgical |
$500 |
20% after deductible |
$250 |
20% after deductible |
| Hospital Stay |
$1,000 |
20% after deductible |
$500 |
20% after deductible |
| Out-of-Pocket Maximum |
$2,000 per individual
$4,000 per family |
$4,000 per individual
$8,000 per family |
$1,000 per individual
$2,000 per family |
$3,000 per individual
$6,000 per family |
| Out-of-Pocket Maximum Includes: |
Services with a copayment of $100 or greater |
Deductible and 20% coinsurance |
Services with a copayment of $250 or greater |
Deductible and 20% coinsurance |
| Prescription Drugs |
|
