Comparison of Benefits
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- Donna Blankenship
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1 2018 Comparison of Benefits for Large Groups HMO POS myfhca.org (3/20/2018) 17FLG-COMPBEN6
2 Care Advantage Large Group HMO Plans CT, MRI, HF13 HMO % $0 $1,500 / $3,000 $15 $15 $0 $50 per visit, per type $75 $30 $250 per, $500 max. per calendar year $150 HF15 HMO % $0 $1,500 / $3,000 $15 $25 $0 $50 per visit, per type $75 $30 $200 per day, $1,000 max. per calendar year $150 HF1 HMO % $0 $2,000 / $4,000 $10 $20 $50 per visit, per type $100 $30 $200 per $150 Value 5 HMO 6049 $0 $2,000 / $4,000 $15 $30 $150 $30 Value 6 HMO % $0 $2,500 / $5,000 $20 $40 25% $200 $30 25% 25% HF2 HMO % $0 $3,000 / $6,000 $15 $30 X-rays 15% $75 per visit, per type $150 $30 $250 per $200 Value 7 HMO % $0 $3,000 / $6,000 $25 $50 30% $250 $40 30% 30% HF4 HMO 6031 $0 $4,000 / $8,000 $20 $40 $100 per visit, per type $200 $30 $200 per day (1 5) per $250 C3 HMO % $0 $5,000 / $10,000 $25 $50 50% 50% 50% $50 $1,500 per 50% HF5 HMO % $0 $5,000 / $10,000 $20 $40 $200 per visit, per type $300 $30 $1,000 per $250 Value 8 HMO % $0 $5,000 / $10,000 $30 $60 X-rays 35% 35% $300 $40 35% 35% HF6 HMO % $0 $6,000 / $12,000 $30 $50 X-rays 15% $200 per visit, per type $400 $30 $1,500 per $300 C1 HMO % $0 $6,350 / $12,700 $25 50% 50% 50% 50% $50 50% 50% Value 5D HMO 6051 $250 / $500 $2,000 / $4,000 $15 $30 $150 $30 Value 10D HMO 6067 $250 / $500 $3,000 / $6,000 $15 $30 X-rays $30 $100 per visit, per type $150 $30 $500 per $ D HMO 6045 $250 / $500 $4,000 / $8,000 $20 $40 $100 per visit, per type $200 $30 $200 per day (1 5) per $250
3 Care Advantage Large Group HMO Plans CT, MRI, Value 6D HMO % $500 / $1,000 $2,500 / $5,000 $20 $40 25% $200 $30 25% 25% 500D HMO 6154 $500 / $1,000 $3,500 / $7,000 $25 $40 $75 $ D HMO % $750 / $1,500 $1,500 / $3,000 $20 $30 X-rays $50 10% $150 $20 10% 10% Value 7D HMO % $750 / $1,500 $3,000 / $6,000 $25 $50 30% $250 $40 30% 30% 1000/80 HMO 6069 $1,000 / $2,000 $3,000 / $6,000 $25 $40 $200 $50 $ /80 HMO 6076 $1,000 / $2,000 $4,000 / $8,000 $25 $40 $75 $650 Value 8D HMO % $1,000 / $2,000 $5,000 / $10,000 $30 $60 X-rays 35% 35% $300 $40 35% 35% 1500/80 HMO 6071 $1,500 / $3,000 $3,500 / $7,000 $30 $45 $200 $50 $ /80 HMO 6077 $1,500 / $3,000 $4,500 / $9,000 $30 $45 $75 $650 Value 9D HMO 6065 $1,500 / $4,500 $5,000 / $10,000 $25 $50 X-rays $50 $100 per visit, per type $150 $50 $ /80 HMO 6073 $2,500 / $5,000 $4,500 / $9,000 $35 $50 $200 $50 $ /80 HMO 6078 $2,500 / $5,000 $5,500 / $11,000 $35 $50 $75 $650 HF16 HMO 6043 $3,000 / $6,000 $5,000 / $10,000 $15 $25 $75 $30 $ / $3,500 / $7,000 $5,500 / $11,000 $35 $50 $75 $1,650 $ / $4,500 / $9,000 $7,350 / $14,700 $35 $50 $75 $1,650 $ /80 HMO 6075 $5,000 / $10,000 $6,350 / $12,700 $35 $50 $200 $50 $ /80 HMO 6079 $5,000 / $10,000 $6,350 / $12,700 $35 $50 $75 $650
4 Care Advantage Large Group HMO Plans CT, MRI, 5000/65 HMO % $5,000 / $10,000 $6,600 / $13,200 $30 $60 X-rays 35% 35% 35% 35% 35% 35% 6600/100 HMO % $6,600 / $13,200 $6,600 / $13,200 $50 0% 0% 0% 0% $75 0% 0% HMO HSA Qualified CT, MRI, HDHMO 1500 HSA 6082 HDHMO 2500 HSA 6084 HDHMO 6350 HSA 6088 $1,500* / $3,000 $3,000 / $6,000 $2,500* / $5,000 $5,000 / $10,000 0% $6,350* / $12,700 $6,350 / $12,700 0% 0% 0% 0% 0% 0% 0% 0% This Benefit Grid is intended only to highlight the Benefits and should not be relied upon to fully determine coverage. If this Benefit Grid conflicts in any way with the Schedule of Benefits, the Schedule shall prevail. (9/26/2017) This is a summary of benefits only. Limitations and prior authorization requirements may apply to certain services. Consult your Certificate of Coverage for a complete listing of services and cost share amounts. Health First Commercial Plans, Inc. is doing business under the name of Care Advantage. Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
5 Care Advantage Large Group POS Plans Out-of-Pocket In-Network (including Behavioral Health s) Testing (Routine Labs & X-rays) Imaging Hospital Admission Surgery (Facility) In- and Outof-Network Out-of-Network Out-of- Pocket PS2 POS % $0 $2,000 / $4,000 $15 $30 $150 $50 $250 per $200 $100 $500 / $1,500 $4,000 / $8,000 Value 5 POS 6106 $0 $2,000 / $4,000 $15 $30 $40 $150 40% $500 / $1,000 $4,000 / $8,000 Value 9 POS % $0 $2,000 / $4,000 $15 10% Routine lab $0 X-rays: $0 10% $15 10% 10% $100 30% $500 / $1,000 $4,000 / $8,000 Value 6 POS % $0 $2,500 / $5,000 $20 $40 25% $40 25% 25% $200 40% $1,000 / $2,000 $6,000 / $12,000 Value 7 POS % $0 $3,000 / $6,000 $25 $50 30% $40 30% 30% $250 50% $1,500 / $3,000 $6,000 / $12,000 PS4 POS 6104 $0 $4,000 / $10,000 $20 $40 $150 $50 $200 per day (1 5) per $250 $200 30% $1,000 / $3,000 $6,000 / $12, D POS % $250 / $500 $2,000 / $4,000 $15 $30 $150 $50 $250 per $200 $100 $500 / $1,500 $4,000 / $8,000 Value 5D POS 6108 $250 / $500 $2,000 / $4,000 $15 $30 $40 $150 40% $500 / $1,000 $4,000 / $8,000 Value 6D POS % $500 / $1,000 $2,500 / $5,000 $20 $40 25% $40 25% 25% $200 40% $1,000 / $2,000 $6,000 / $12, D POS 6155 $500 / $1,000 $3,500 / $7,000 $20 $40 $75 $650 $300 1st 40% $1,000 / $2,000 $7,000 / $14,000 Value 7D POS % $750 / $1,500 $3,000 / $6,000 $25 $50 30% $40 30% 30% $250 50% $1,500 / $3,000 $6,000 / $12, /80 POS 6090 $1,000 / $2,000 $3,000 / $6,000 $25 $40 $50 $250 $200 40% $2,000 / $4,000 $6,000 / $12, /80 POS 6119 $1,000 / $2,000 $4,000 / $8,000 $25 $40 $75 $650 $300 1st 40% $2,000 / $4,000 $8,000 / $16, D POS 6100 $1,250 / $2,500 $2,000 / $4,000 $30 $40 $30 $300 40% $2,000 / $4,000 $4,000 / $8, /80 POS 6092 $1,500 / $3,000 $3,500 / $7,000 $30 $45 $50 $250 $200 40% $3,000 / $6,000 $7,000 / $14, /80 POS 6120 $1,500 / $3,000 $4,500 / $9,000 $30 $45 $75 $650 $300 1st 40% $3,000 / $6,000 $9,000 / $18, /80 POS 6094 $2,500 / $5,000 $4,500 / $9,000 $35 $50 $50 $250 $200 40% $5,000 / $15,000 $9,000 / $18, /80 POS 6121 $2,500 / $5,000 $5,500 / $11,000 $35 $50 $75 $650 $300 1st 40% $5,000 / $10,000 $11,000 / $22, /80 POS 6096 $5,000 / $10,000 $6,350 / $12,700 $35 $50 $50 $250 $200 40% $10,000 / $20,000 $14,000 / $28, /80 POS 6122 $5,000 / $10,000 $6,350 / $12,700 $35 $50 & $75 $650 $300 1st 40% $10,000 / $20,000 $14,000 / $28,000
6 Care Advantage Large Group POS Plans POS HSA Qualified HDPOS 1500 HSA 6117 HDPOS 2500 HSA 6118 HDPOS 6350 HSA 6140 Out-of-Pocket In-Network (including Behavioral Health s) Testing (Routine Labs & X-rays) Imaging Hospital Admission Surgery (Facility) In- and Outof-Network Out-of-Network Out-of- Pocket $1,500* / $3,000 $3,000 / $6,000 40% $3,000* / $6,000 $6,000 / $12,000 $2,500* / $5,000 $5,000 / $10,000 40% $5,000* / $10,000 0% $6,350* / $12,700 $6,350/$12,700 0% 0% 0% 0% 0% 0% 0% 0% 0% $12,700* / $25,400 $10,000 / $20,000 $12,700 / $25,400 Eye exams are included in well-child exams for all plans. *Individual deductible amount does not apply if policy covers two or more people. This Benefit Grid is intended only to highlight the Benefits and should not be relied upon to fully determine coverage. If this Benefit Grid conflicts in any way with the Schedule of Benefits, the Schedule shall prevail. (9/26/2017) This is a summary of benefits only. Limitations and prior authorization requirements may apply to certain services. Consult your Certificate of Coverage for a complete listing of services and cost share amounts. Health First Commercial Plans, Inc. is doing business under the name of Care Advantage. Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
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