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| Large Groups: 51+ Eligible Employees | |||||||||||||||||
| Plans | Basic HMO | Value HMO | Premium HMO | Preferred Provider Organization (PPO) | |||||||||||||
| HNE Wise Plus HDHP M HMO |
HNE WiseMax HDHP H HMO |
HNE EssentialPlus Option 9M |
HNE EssentialMax Option 9H |
HNE Focus * Option 8H |
HNE Choice Option 7L |
HNE ChoicePlus Option 7M |
HNE CompletePlus Option 7H |
HNE CompleteMax * Option 5 |
HNE Principle * Option 4 |
HNE HealthMax Option 3 |
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 per policy OR calendar year |
$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 | N/A | N/A | N/A | N/A | N/A | N/A | $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
$25 after deductible for all other office visits |
$0 Preventive Services
$0 after deductible for all other office visits
|
$0 Preventive
Services
$30 PCP $40 Specialist after deductible |
$0 Preventive Services
$20 PCP $40 Specialist |
$0 Preventive
Services
$25 All other office visits |
$0 Preventive Servicea $20 PCP $40 Specialist |
$0 Preventive Services $20 PCP $40 Specialist |
$0 Preventive Services $10 PCP $25 Specialist |
$0 Preventive Services $20 |
$0 Preventive Services $15 |
$0 Preventive Services $10 |
$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) |
$75 after deductible | $0 after deductible | $100 after deductible | $100 after deductible | $100 per visit | $100 per visit | $75 per visit | $50 per visit | $50 per visit | $50 per visit | $50 per visit | $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 | $0 after deductible | $0 after deductible | $100 after deductible | $150 | $0 | $0 | $0 | $0 | $0 | $0 | $0 after deductible | 20% after deductible | $0 | 20% after deductible | $0 | 20% after deductible |
| Outpatient Surgical | $250 after deductible | $0 after deductible | $250 after deductible | $0 after deductible | $500 | $500 | $250 | $250 | $250 | $150 | $0 | $0 after deductible | 20% after deductible | $250 | 20% after deductible | $250 | 20% after deductible |
| Hospital Stay | $500 after deductible | $0 after deductible | $500 after deductible | $0 after deductible | $1,000 | $1,000 | $500 | $500 | $500 | $250 | $0 | $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 |
$5,000 per individual
$10,000 per family |
$3,000 per individual
$6,000 per family |
$2,000 per individual
$4,000 per family |
$2,000 per individual
$4,000 per family |
$2,000 per individual
$4,000 per family |
$1,000 per individual
$2,000 per family |
$1,000 per individual
$2,000 per family |
$1,000 per individual
$2,000 per family |
$500 per individual
$1,000 per family, |
N/A | $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 copayments | Deductible and services with a copayment of $100 or greater | Deductible and services with a copayment of $100 or greater | Services with a copayment of $100 or greater | Services with a copayment of $100 or greater | Services with a copayment of $250 or greater | Services with a copayment of $250 or greater | Services wth a copayment of $250 or greater | Services with a copayment of $150 or greater | N/A | 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 | Network Options | * Looking for lower premiums? Ask your Sales Representative about the HNE Alliance Network. | PHCS is a national PPO network of over 450,000 providers and 4,000 facilities to choose from. | ||||||||||||||