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| PPO |
| Plans |
Value PPO |
PPO Essential 1000 |
PPO Essential 500 |
PPO Focus |
| In-Plan |
Out-of-Plan |
In-Plan
|
Out-of-Plan |
In-Plan |
Out-of-Plan |
| Deductible |
$1,000 per individual
$2,000 per family
per policy or calendar year |
$1,000 per individual
$2,000 per family
per policy or calendar year |
$500 per individual
$1,000 per family
per policy or calendar year |
$500 per individual
$1,000 per family
per policy or calendar year |
N/A |
$1,000 per Individual
$2,000 per Family per calendar year |
| Doctor’s Office |
$0 Preventive Services
$20 for all other office visits |
20% after deductible |
$0 Preventive Services
$20 All other office visits |
20% after deductible |
$0 Preventive Services
$25 All other office visits |
20% after deductible |
Emergency Room
(waived if admitted directly from ER) |
$150 per visit |
$150 per visit |
$150 per visit |
$150 per visit |
$150 per visit |
$150 per visit |
High Cost Diagnostics:
Diagnostic Imaging:
CT Scans, MRI, PET Scans
Sleep Studies
Genetic Testing: BRCA & Colaris |
$75 after deductible |
20% after deductible |
$75 after deductible |
20% after deductible |
$100 |
20% after deductible |
| $75 after deductible |
20% after deductible |
$75 after deductible |
20% after deductible |
$100 |
20% after deductible |
| $75 after deductible |
20% after deductible |
$75 after deductible |
20% after deductible |
$100 |
20% after deductible |
| Outpatient Surgery |
$0 after deductible |
20% after deductible |
$0 after deductible |
20% after deductible |
$500 |
20% after deductible |
| Hospital Admission |
$0 after deductible |
20% after deductible |
$0 after deductible |
20% after deductible |
$1,000 |
20% after deductible |
| Out-of-Pocket Maximum |
$2,000 per individual
$4,000 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
|
$2,000 per individual
$4,000 per family |
$4,000 per individual
$8,000 per family |
| Out-of-Pocket Maximum Includes: |
Deductible and services with a copayment of $100 or greater |
Deductible and coinsurance |
Deductible and services with a copayment of $100 or greater |
Deductible and coinsurance |
Services with a copayment of $100 or greater |
Deductible and coinsurance |
| Prescription Drugs |
|
| HNE offers a PHCS version of these plans. PHCS is a national PPO network of over 450,000 providers and 4,000 facilities to choose from. |
