450A HIP HMO Low
HIP Prime Network (gated)
Gated in-network HMO — no medical deductible, $30 office / $75 specialist copays, $25 generic-only Rx card, $2,000 inpatient copay. $7,350/$14,700 out-of-pocket max.
Monthly premiums
- Member
- $1,547.00/mo
- Member & Spouse
- $2,812.00/mo
- Member & Children
- $2,812.00/mo
- Member & Family
- $4,201.00/mo
$0-deductible HMO at a lower rate — same $30/$75 copays, generic-only Rx
Plan details
- Deductible (Individual)
- $0
- Deductible (Family)
- $0
- Out-of-Pocket Max (Individual)
- $7,350
- Out-of-Pocket Max (Family)
- $14,700
- Coinsurance (In-Network)
- 0%
- Primary Care Copay
- $30
- Specialist Copay
- $75
- Urgent Care Copay
- $30
- ER Copay
- $300
Benefits
Deductible
$0
OON: Not Covered
Max Out of Pocket
$7,350 / $14,700
OON: Not Covered
Copay
$30 / $75 / $30
PCP / Specialist / Urgent Care
Coinsurance
0%
Copays only, no deductible
Emergency Room
$300 copay
Waived if admitted
Rx Coverage
$25 generic
Tier 1 only; $37.50 mail order / 90 days
Pregnancy
Covered
$30 visits; $1,000 delivery facility copay
Mental Health
Covered
$30 outpatient; $2,000 inpatient
Hospital Admission
$2,000 per admission
Preauthorization required
Referrals
Required
Gated HMO — care through your PCP
Dependents
To Age 26
Coverage
In-network only
HIP Prime Network
Work Requirement
Work Required
Plan documents
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