Comparison of Benefits
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1 2019 Comparison of Benefits for Large Groups HMO POS Access POS myhfhp.org 9/24/ HLG-COMPBEN3
2 Health First Large Group HMO Plans Out of Pocket Max. Specialist Office Diagnostic Testing (Routine Labs & X-rays) Advanced Imaging Inpatient Admissions Outpatient Surgery Health First HF15 HMO % $0 $1,500 / $3,000 $15 $25 $0 $50 $30 $75 $200 per day, $1,000 max. per calendar year $150 Health First HF1 HMO % $0 $2,000 / $4,000 $10 $20 X-rays 10% $50 per visit, per $30 $100 $200 per $150 Health First Value 5 HMO 6048 $0 $2,000 / $4,000 $15 $30 $30 $150 Health First Value 6 HMO % $0 $2,500 / $5,000 $20 $40 X-rays 25% 25% $30 $200 25% Health First HF2 HMO % $0 $3,000 / $6,000 $15 $30 X-rays 15% $75 per visit, per $30 $150 per $200 Health First Value 7 HMO % $0 $3,000 / $6,000 $25 $50 X-rays 30% 30% $40 30% 30% Health First HF4 HMO 6030 $0 $4,000 / $8,000 $20 $40 $30 $200 $200 per day Health First HF5 HMO % $0 $5,000 / $10,000 $20 $40 X-rays 10% $200 per visit, per $30 $300 $1,000 per Health First Value 8 HMO % $0 $5,000 / $10,000 $30 $60 X-rays 35% 35% $40 $300 35% 35% Health First C3 HMO % $0 $5,000 / $10,000 $25 $50 50% 50% $50 50% $1,500 per 50% Health First HF6 HMO % $0 $6,000 / $12,000 $30 $50 X-rays 15% $200 per visit, per $30 $400 $1,500 per $300 Health First Value 5D HMO 6050 / $500 $2,000 / $4,000 $15 $30 $30 $150 Health First Value 10D HMO 6066 / $500 $3,000 / $6,000 $15 $30 X-rays $30 $30 $150 $500 per $300 Health First 250D HMO 6044 / $500 $4,000 / $8,000 $20 $40 $30 $200 $200 per day Health First Value 6D HMO % $500 / $1,000 $2,500 / $5,000 $20 $40 X-rays 25% 25% $30 $200 25% Health First 500D HMO 6152 $500 / $1,000 $3,500 / $7,000 $25 $40 $1,650 per $650
3 Health First Large Group HMO Plans Out of Pocket Max. Specialist Office Diagnostic Testing (Routine Labs & X-rays) Advanced Imaging Inpatient Admissions Outpatient Surgery Health First 750D HMO % $750 / $1,500 $1,500 / $3,000 $20 $30 X-rays $50 10% $20 $150 10% 10% Health First Value 7D HMO % $750 / $1,500 $3,000 / $6,000 $25 $50 X-rays 30% 30% $40 30% 30% HMO 6068 $1,000 / $2,000 $3,000 / $6,000 $25 $40 $50 $200 HMO 6001 $1,000 / $2,000 $4,000 / $8,000 $25 $40 $650 Health First Value 8D HMO % $1,000 / $2,000 $5,000 / $10,000 $30 $60 X-rays 35% 35% $40 $300 35% 35% HMO 6070 $1,500 / $3,000 $3,500 / $7,000 $30 $45 $50 $200 HMO 6002 $1,500 / $3,000 $4,500 / $9,000 $30 $45 $650 Health First Value 9D HMO 6064 $1,500 / $4,500 $5,000 / $10,000 $25 $50 X-rays $50 $50 $150 $200 HMO 6072 $2,500 / $5,000 $4,500 / $9,000 $35 $50 $50 $200 HMO 6003 $2,500 / $5,000 $5,500 / $11,000 $35 $50 $650 Health First HF16 HMO 6042 $3,000 / $6,000 $5,000 / $10,000 $15 $25 $30 $75 $1,500 $150 Health First 3500/80 HMO 6181 $3,500 / $7,000 $5,500 / $11,000 $35 $50 $1,650 $650 Health First 4000/80 HMO 6186 $4,000 / $8,000 $6,600 / $13,200 $35 $50 $650 Health First 4500/80 HMO 6183 $4,500 / $9,000 $7,350 / $14,700 $35 $50 $1,650 $650 HMO 6004 $5,000 / $10,000 $6,350 / $12,700 $35 $50 $650 HMO 6074 $5,000 / $10,000 $6,350 / $12,700 $35 $50 $50 $200 Health First 5000/65 HMO % $5,000 / $10,000 $6,600 / $13,200 $30 $60 X-rays 35% 35% 35% 35% 35% 35% Health First 6600/100 HMO % $6,600 / $13,200 $6,600 / $13,200 $50 0% 0% 0% $75 0% 0% 0%
4 Health First Large Group HMO Plans Health First Large Group HMO Plans - HSA Qualified Out of Pocket Max. Specialist Office Diagnostic Testing (Routine Labs & X-rays) Outpatient CT, MRI, MRA, PET Scans and Nuclear Cardiology Studies Inpatient Admissions Outpatient Surgery 1500 HSA HSA HSA HSA HSA HSA 6087 $1,500* / $3,000 $3,000 / $6,000 $2,500* / $5,000 $5,000 / $10,000 $3,500* / $7,000 $5,000 / $10,000 $4,500* / $9,000 $6,350 / $12,700 $5,000* / $10,000 $6,650 / $13,300 0% $6,350* / $12,700 $6,350 / $12,700 0% 0% 0% 0% 0% 0% 0% 0% Eye exams are included in well-child exams for all plans. *Individual deductible amount does not apply if policy covers 2 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. (9/24/2018) 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 Health Plans is underwritten by Health First Commercial Plans, Inc. Health First Commercial Plans, Inc. 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 Health First Large Group POS Plans In-Network In- and Out-of-Network (IN / OON) Out-of-Network Out of Pocket Specialist Office Diagnostic Testing (Routine Labs & X-rays) Advanced Imaging Hospital Admission Outpatient Surgery Individual / Out-of-Pocket Health First PS2 POS % $0 $2,000 / $4,000 $15 $30 X-rays 10% $150 per $200 $50 $100 $500 / $1,500 $4,000 / $8,000 Health First Value 5 POS 6105 $0 $2,000 / $4,000 $15 $30 $40 $150 $500 / $1,000 $4,000 / $8,000 Health First Value 9 POS % $0 $2,000 / $4,000 $15 10% X-rays $0 10% 10% 10% $15 IN $40 OON $100 30% $500 / $1,000 $4,000 / $8,000 Health First PS4 POS 6103 $0 $4,000 / $10,000 $20 $40 $150 $200 per day $50 $200 30% $500 / $1,000 $8,000 / $16,000 Health First Value 5D POS 6107 / $500 $2,000 / $4,000 $15 $30 $40 $150 $500 / $1,000 $4,000 / $8,000 Health First Value 6D POS % $500 / $1,000 $2,500 / $5,000 $20 $40 X-rays 25% 25% 25% 25% $40 $200 $1,000 / $2,000 $6,000 / $12,000 Health First 500D POS 6153 $500 / $1,000 $3,500 / $7,000 $25 $40 $1,650 $650 $1,000 / $2,000 $7,000 / $14,000 Health First Value 7D POS % $750 / $1,500 $3,000 / $6,000 $25 $50 X-rays 30% 30% 30% 30% $40 50% $1,500 / $3,000 $6,000 / $12,000 POS 6089 $1,000 / $2,000 $3,000 / $6,000 $25 $40 $200 $2,000 / $4,000 $6,000 / $12,000 POS 6005 $1,000 / $2,000 $4,000 / $8,000 $25 $40 $650 $2,000 / $4,000 $8,000 / $16,000 Health First 1250D POS 6099 $1,250 / $2,500 $2,000 / $4,000 $30 $40 $30 $300 $2,000 / $4,000 $4,000 / $8,000 POS 6091 $1,500 / $3,000 $3,500 / $7,000 $30 $45 $200 $3,000 / $6,000 $7,000 / $14,000 POS 6006 $1,500 / $3,000 $4,500 / $9,000 $30 $45 $650 $3,000 / $6,000 $9,000 / $18,000 POS 6093 $2,500 / $5,000 $4,500 / $9,000 $35 $50 $200 $5,000 / $15,000 $9,000 / $18,000 POS 6007 $2,500 / $5,000 $5,500 / $11,000 $35 $50 $650 $5,000 / $10,000 $11,000 / $22,000 Health First 3500/80 POS 6188 $3,500 / $7,000 $5,500 / $ 11,000 $35 $50 $1,650 $650 $7,000 / $14,000 $11,000 / $22,000 Health First 4500/80 POS 6190 $4,500 / $ 9,000 $7,350 / $14,700 $35 $50 $1,650 $650 $9,000 / $18,000 $14,700 / $29,400 POS 6095 $5,000 / $10,000 $6,350 / $12,700 $35 $50 $50 $200 $10,000 / $20,000 $14,000 / $28,000 POS 6008 $5,000 / $10,000 $6,350 / $12,700 $35 $50 $650 $75 $10,000 / $20,000 $14,000 / $28,000
6 Health First Large Group POS Plans - HSA Qualified In-Network In- and Out-of-Network (IN / OON) Out-of-Network Out of Pocket Specialist Office Diagnostic Testing (Routine Labs & X-rays) Advanced Imaging Hospital Admission Outpatient Surgery Individual / Out-of-Pocket 1500 HSA 6010 $1,500* / $3,000 $3,000 / $6,000 IN $3,000* / $6,000 $6,000 / $12, HSA 6011 $2,500* / $5,000 $5,000 / $10,000 IN $5,000* / $10,000 $10,000 / $20, HSA 6198 $3,500* / $7,000 $5,000 / $10,000 IN $7,000* / $14,000 $10,000 / $20, HSA 6200 $4,500* / $ 9,000 $6,350 / $12,700 IN $9,000* / $18,000 $12,700 / $25, HSA 6202 $5,000* / $10,000 $6,650 / $13,300 IN $10,000* / $20,000 $13,300 / $26, HSA % $6,350* / $12,700 $6,350 / $12,700 0% 0% 0% 0% 0% 0% 0% 0% 0% $12,700* / $25,400 $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. (9/24/2018) 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 Health Plans is underwritten by Health First Commercial Plans, Inc. Health First Commercial Plans, Inc. 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.
7 Health First Large Group Access POS Plans In-Network In- and Out-of- Network Out-of-Network Out of Pocket Specialist Office Diagnostic Testing (Routine Labs & X-rays) Advanced Imaging Hospital Admission Outpatient Surgery Individual / Out-of-Pocket POS % $500 / $1,500 $6,000 / $12,000 $25 $50 X-rays 50% 50% $1,000 50% 50% 50% 50% $1,000 / $3,000 $12,000 / $24,000 POS POS POS $500 / $1,000 $3,000 / $6,000 $20 $40 $500 / $1,000 $4,000 / $8,000 $20 $40 $500 / $1,000 $5,000 / $10,000 $20 $40 per day per day per day 30% $1,000 / $2,000 $6,000 / $12,000 30% $1,000 / $2,000 $8,000 / $16,000 30% $1,000 / $2,000 $10,000 / $20,000 POS % $1,000 / $3,000 $6,350 / $12,700 $30 $60 X-rays 50% 50% $1,500 50% 50% 50% 50% $2,000 / $6,000 $12,000 / $24,000 POS POS $1,500 / $3,000 $4,500 / $9,000 $20 $40 $2,500 / $5,000 $5,000 / $10,000 $20 $40 per day per day 30% $3,000 / $6,000 $9,000 / $18,000 30% $5,000 / $10,000 $10,000 / $20,000 POS % $3,000 / $9,000 $6,350 / $12,700 $35 50% X-rays 50% 50% 50% 50% 50% 50% 50% $6,000 / $18,000 $12,000 / $24,000 POS $5,000 / $10,000 $6,350 / $12,700 $20 $40 per day 30% $10,000 / $20,000 $20,000 / $30,000 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. (9/24/2018) 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 Health Plans is underwritten by Health First Commercial Plans, Inc. Health First Commercial Plans, Inc. 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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