450A HIP Select 4000
HIP Select Care Network (gated)
Gated in-network plan — $4,000/$8,000 deductible, $30 office copay, $60 specialist after deductible, $15 generic-only Rx card. $6,000/$12,000 out-of-pocket max.
Monthly premiums
- Member
- $1,285.00/mo
- Member & Spouse
- $2,255.00/mo
- Member & Children
- $2,255.00/mo
- Member & Family
- $3,465.00/mo
Lowest-cost 450A HIP option — $30 PCP copay before the deductible, $1,285/mo single
Plan details
- Deductible (Individual)
- $4,000
- Deductible (Family)
- $8,000
- Out-of-Pocket Max (Individual)
- $6,000
- Out-of-Pocket Max (Family)
- $12,000
- Coinsurance (In-Network)
- 0%
- Primary Care Copay
- $30
- Specialist Copay
- $60
- Urgent Care Copay
- $75
Benefits
Deductible
$4,000 / $8,000
OON: Not Covered
Max Out of Pocket
$6,000 / $12,000
OON: Not Covered
Copay
$30 / $60 / $75
PCP (no ded) / Specialist / Urgent Care after ded
Coinsurance
0%
Copays after deductible
Emergency Room
$200 copay
After deductible; waived if admitted
Rx Coverage
$15 generic
Tier 1 only; $30 mail order / 90 days
Pregnancy
Covered
$30 visits; $1,000 delivery facility copay
Mental Health
Covered
$30 outpatient (no ded); $750 inpatient
Hospital Admission
$750 per admission
After deductible
Referrals
Required
Gated HMO — care through your PCP
Dependents
To Age 26
Coverage
In-network only
HIP Select Care Network
Work Requirement
Work Required
Plan documents
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