HMO Individual HMO Plans Comparison of Benefits. Page 1
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- Bethany Parks
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1 2015 Individual HMO Plans Comparison of Benefits HMO (including 15 Routine Specialist Visit (including Behavioral HF Platinum HMO Select % $800 / $1,600 $1,000 / $2,000 $0 $15 $35 $35 0% HF Platinum HMO Select % $750 / $1,500 $1,500 / $3,000 $0 Visits 1-3, $0; Visits 4+, $15 $20 $20 10%, $0 for Diagnostic Labs HF Platinum HMO Select % $450 / $900 $1,700 / $3,400 $0 Visits 1-3, $0; Visits 4+, $20 $20 $20 20%, $0 for Diagnostic Labs HF Gold HMO Select % $2,600 / $5,200 $2,800 / $5,600 $0 $20 $40 $40 0% HF Gold HMO Select % $1,300 / $2,600 $3,000 / $6,000 $0 10% 10% 10% 10% HF Gold HMO Select % $1,500 / $3,000 $3,000 / $6,000 $0 10% 10% 10% 10% HF Gold HMO Select % $1,500 / $3,000 $4,000 / $8,000 $0 $15 $30 $30 20% : : : Copay applies to first 5 visits, then 20% : : : $600/admission for Inpatient Care HF Gold HMO Select % $1,000 / $2,000 $2,500 / $5,000 $0 Visits 4+, 20% 20% 20% HF Gold HMO Select % $1,000 / $2,000 $6,350 / $12,700 $0 20% $350 for $20 $40 $40 20% : : : Copay applies to first 3 visits, then 20% : : : $875/admission for Inpatient Care, $250 for Outpatient Surgery, $150 for Specialty Imaging HF Gold HMO Select % $2,000 / $4,000 $4,000 / $8,000 $0 $15 $30 $30 20%, $0 for Diagnostic Labs HF Gold HMO Select % $1,000 / $2,000 $2,900 / $5,800 $0 30% 30% 30% 30% HF Gold HMO Select % $1,000 / $2,000 $3,000 / $6,000 $0 $35 $50 $50 : : : Copay applies to first 4 visits, then 30% : : : 30%, $0 for Diagnostic Labs HF Gold HMO Select % $1,000 / $2,000 $2,000 / $4,000 $0 50% 50% 50% 50% HF Silver HMO Select % $3,800 / $7,600 $4,000 / $8,000 $0 then $25 0% HF Silver HMO Select % $4,400 / $8,800 $4,600 / $9,200 $0 $50 0% 0% 0% HF Silver HMO Select % $2,600 / $5,200 $6,350 / $12,700 $0 $40 10% HF Silver HMO Select % $3,000 / $6,000 $6,000 / $12,000 $0 $25 10% HF Silver HMO Select % $2,000 / $4,000 $4,500 / $9,000 $0 15% 15% 15% 15% HF Silver HMO Select % $2,500 / $5,000 $6,350 / $12,700 $0 20% 20% 20% 20% HF Silver HMO Select % $2,000 / $4,000 $4,600 / $9,200 $0 30% 30% 30% 30% HF Silver HMO Select % $3,500 / $7,000 $6,350 / $12,700 $0 $35 $50 $50 HF Bronze HMO Select % $6,000 / $12,000 $6,000 / $12,000 $0 0% 0% 0% 0% HF Bronze HMO Select % $6,000 / $12,000 $6,350 / $12,700 $0 10% 10% 10% HF Bronze HMO Select % $4,000 / $8,000 $6,350 / $12,700 $0 20% 20% 20% 20% HF Bronze HMO Select % $4,600 / $9,200 $6,350 / $12,700 $0 $50 30% 30% 30% HF Catastrophic HMO Select % $6,600 / $13,200 $6,600 / $13,200 $0 Visits 4+, 0% 0% 0% 0% 30% 5-tier Formulary, Single ( waived for Tiers 1-2) $0 Rx $0 Rx 10% after 50% after 0% after 10/20/40/60/30% $350 Rx 20% after 30% after 0% after Page 1
2 2015 Individual HMO Plans Comparison of Benefits Cost-Share Reduction Variations HMO CSR Pediatric Dental (including 15 Routine Specialist Visit (including Behavioral 5-tier Formulary, Single ( waived for Tiers 1-2) HF Silver HMO Select HF Silver AV94 HMO Select ( % FPL) 100% $100 / $200 $400 / $800 $0 $5 $50 $50 0% HF Silver AV87 HMO Select ( % FPL) 100% $900 / $1,800 $1,300 / $2,600 $0 $5 $50 $50 0% HF Silver AV73 HMO Select ( % FPL) 100% $2,900 / $5,800 $3,200 / $6,400 $0 then $25 0% HF Silver HMO Select HF Silver AV94 HMO Select ( % FPL) 100% $150 / $300 $400 / $800 $0 $5 0% 0% 0% HF Silver AV87 HMO Select ( % FPL) 100% $900 / $1,800 $1,300 / $2,600 $0 $5 0% 0% 0% HF Silver AV73 HMO Select ( % FPL) 100% $3,200 / $6,400 $4,600 / $9,200 $0 $50 0% 0% 0% HF Silver HMO Select HF Silver AV94 HMO Select ( % FPL) 90% $0 / $0 $650 / $1,300 $0 $5 $50 $50 10% HF Silver AV87 HMO Select ( % FPL) 90% $350 / $700 $2,250 / $4,500 $0 $5 $50 $50 10% HF Silver AV73 HMO Select ( % FPL) 90% $2,500 / $5,000 $5,200 / $10,400 $0 $25 10% HF Silver HMO Select HF Silver AV94 HMO Select ( % FPL) 90% $0 / $0 $600 / $1,200 $0 $5 $60 $60 10% HF Silver AV87 HMO Select ( % FPL) 90% $250 / $500 $2,250 / $4,500 $0 $5 $60 $60 10% HF Silver AV73 HMO Select ( % FPL) 90% $2,100 / $4,200 $5,200 / $10,400 $0 $40 10% HF Silver HMO Select HF Silver AV94 HMO Select ( % FPL) 85% $0 / $0 $1,000 / $2,000 $0 15% 15% 15% 15% HF Silver AV87 HMO Select ( % FPL) 85% $400 / $800 $2,250 / $4,500 $0 15% 15% 15% 15% HF Silver AV73 HMO Select ( % FPL) HF Silver HMO Select % $1,650 / $3,300 $4,500 / $9,000 $0 15% 15% 15% 15% HF Silver AV94 HMO Select ( % FPL) 80% $200 / $400 $500 / $1,000 $0 20% 20% 20% 20% $250 Rx HF Silver AV87 HMO Select ( % FPL) 80% $700 / $1,400 $1,250 / $2,500 $0 20% 20% 20% 20% $250 Rx HF Silver AV73 HMO Select ( % FPL) 80% $2,500 / $5,000 $3,800 / $7,600 $0 20% 20% 20% 20% HF Silver HMO Select HF Silver AV94 HMO Select ( % FPL) 70% $0 / $0 $600 / $1,200 $0 30% 30% 30% 30% HF Silver AV87 HMO Select ( % FPL) 70% $0 / $0 $2,000 / $4,000 $0 30% 30% 30% 30% HF Silver AV73 HMO Select ( % FPL) 70% $1,300 / $2,600 $4,600 / $9,200 $0 30% 30% 30% 30% HF Silver HMO Select HF Silver AV94 HMO Select ( % FPL) 70% $0 / $0 $600 / $1,200 $0 30% 30% 30% 30% HF Silver AV87 HMO Select ( % FPL) 70% $0 / $0 $2,000 / $4,000 $0 30% 30% 30% 30% HF Silver AV73 HMO Select ( % FPL) 70% $1,200 / $2,400 $5,200 / $10,400 $0 30% 30% 30% 30% HF Silver HMO Select HF Silver AV94 HMO Select ( % FPL) 70% $0 / $0 $600 / $1,200 $0 $35 $50 $50 30% HF Silver AV87 HMO Select ( % FPL) 70% $800 / $1,600 $1,500 / $3,000 $0 $35 $50 $50 30% HF Silver AV73 HMO Select ( % FPL) 70% $3,000 / $6,000 $5,000 / $10,000 $0 $35 $50 $50 30% Page 2
3 2015 Individual POS Plans Comparison of Benefits POS (incl. 15 Routine Specialist Visit (including Behavioral HF Platinum POS Select % $800 / $1,600 $1,000 / $2,000 $0 $15 $35 $35 0% HF Platinum POS Select % $750 / $1,500 $1,500 / $3,000 $0 HF Platinum POS Select % $450 / $900 $1,700 / $3,400 $0 Visits 1-3, $0; Visits 4+, $15 Visits 1-3, $0; Visits 4+, $20 $20 $20 10%, $0 for Diagnostic Labs $20 $20 20%, $0 for Diagnostic Labs HF Gold POS Select % $2,600 / $5,200 $2,800 / $5,600 $0 $20 $40 $40 0% HF Gold POS Select % $1,300 / $2,600 $3,000 / $6,000 $0 10% 10% 10% 10% HF Gold POS Select % $1,500 / $3,000 $3,000 / $6,000 $0 10% 10% 10% 10% HF Gold POS Select % $1,000 / $2,000 $2,500 / $5,000 $0 Visits 4+, 20% 20% 20% 20%, $350 for Emergency Room Services, HF Gold POS Select % $2,000 / $4,000 $4,000 / $8,000 $0 $15 $30 $30 20%, $0 for Diagnostic Labs HF Gold POS Select % $1,500 / $3,000 $4,000 / $8,000 $0 HF Gold POS Select % $1,000 / $2,000 $6,350 / $12,700 $0 $15 $30 $30 20%, $600/admission for Inpatient : : : Copay applies to first 5 visits, then 20% : : : Care, $20 $40 $40 20%, $875/admission for Inpatient Care,, : : : Copay applies to first 3 visits, then 20% : : : $150 for Specialty Imaging HF Gold POS Select % $1,000 / $2,000 $2,900 / $5,800 $0 30% 30% 30% 30% HF Gold POS Select % $1,000 / $2,000 $3,000 / $6,000 $0 $35 $50 $50 : : : Copay applies to first 4 visits, then 30% : : : 30%, $0 for Diagnostic Labs HF Gold POS Select % $1,000 / $2,000 $2,000 / $4,000 $0 50% 50% 50% 50% HF Silver POS Select % $3,800 / $7,600 $4,000 / $8,000 $0 HF Silver POS Select % $4,400 / $8,800 $4,600 / $9,200 $0 $50 0% 0% 0% HF Silver POS Select % $3,000 / $6,000 $6,000 / $12,000 $0 $25 HF Silver POS Select % $2,600 / $5,200 $6,350 / $12,700 $0 $40 HF Silver POS Select then $25 85% $2,000 / $4,000 $4,500 / $9,000 $0 15% 15% 15% 15% HF Silver POS Select % $2,500 / $5,000 $6,350 / $12,700 $0 20% 20% 20% 20% HF Silver POS Select % $2,000 / $4,000 $4,600 / $9,200 $0 30% 30% 30% 30% HF Silver POS Select % $2,000 / $4,000 $6,000 / $12,000 $0 30% 30% 30% 30% HF Silver POS Select % $3,500 / $7,000 $6,350 / $12,700 $0 $35 $50 $50 30% HF Bronze POS Select % $6,000 / $12,000 $6,000 / $12,000 $0 0% 0% 0% 0% HF Bronze POS Select % $6,000 / $12,000 $6,350 / $12,700 $0 HF Bronze POS Select % 10% 10% 10% 10% 10% 80% $4,000 / $8,000 $6,350 / $12,700 $0 20% 20% 20% 20% HF Bronze POS Select % $4,600 / $9,200 $6,350 / $12,700 $0 $50 30% 30% 30% HF Catastrophic POS Select % $6,600 / $13,200 $6,600 / $13,200 $0 Visits 4+, 0% 0% 0% 0% 5-tier Formulary, Single ( waived for Tiers 1-2) $0 Rx $0 Rx 10% after 50% after 0% after 10/20/40/60/30% $350 Rx 20% after 30% after 0% after CY (Separate from in-network OOP max.) 50% $1,600 / $3,200 $2,000 / $4,000 50% $2,250 / $4,500 $4,500 / $9,000 50% $1,350 / $2,700 $5,100 / $10,200 50% $5,200 / $10,400 $5,600 / $11,200 50% $2,600 / $5,200 $6,000 / $12,000 60% $3,000 / $6,000 $6,000 / $12,000 50% $2,000 / $4,000 $5,000 / $10,000 50% $4,000 / $8,000 $8,000 / $16,000 50% $3,000 / $6,000 $8,000 / $16,000 50% $2,000 / $4,000 $12,800 / $25,600 50% $2,000 / $4,000 $5,800 / $11,600 50% $2,000 / $4,000 $6,000 / $12,000 50% $2,000 / $4,000 $4,000 / $8,000 50% $7,600 / $15,200 $8,000 / $16,000 50% $8,800 / $17,600 $9,200 / $18,400 50% $6,000 / $12,000 $12,000 / $24,000 50% $5,200 / $10,400 $12,700 / $25,400 30% $5,000 / $10,000 $12,700 / $25,400 50% $12,000 / $24,000 $12,000 / $24,000 50% $12,000 / $24,000 $12,700 / $25,400 50% $8,000 / $16,000 $12,700 / $25,400 50% $9,200 / $18,400 $12,700 / $25,400 50% $13, 200 / $26,400 $13,200 / $26,400 Page 3
4 POS CSR HF Silver POS Select Pediatric Dental and Vision (incl. 15 Routine PCP Office Visit Specialist Visit (including Behavioral 2015 Individual POS Plans Comparison of Benefits Cost-Share Reduction Variations OP Diagnostic Labs, OP Surgery, X-rays/ Ultrasounds, Inpatient Care, 5-tier Formulary, Single ( waived for Tiers 1-2) CY (separate from in-network OOP max.) HF Silver AV94 POS Select ( % FPL) 100% $100 / $200 $400 / $800 $0 $5 $50 $50 0% 50% $7,600 / $15,200 $8,000 / $16,000 HF Silver AV87 POS Select ( % FPL) 100% $900 / $1,800 $1,300 / $2,600 $0 $5 $50 $50 0% 50% $7,600 / $15,200 $8,000 / $16,000 HF Silver AV73 POS Select ( % FPL) 100% $2,900 / $5,800 $3,200 / $6,400 $0 HF Silver POS Select then $25 0% 50% $7,600 / $15,200 $8,000 / $16,000 HF Silver AV94 POS Select ( % FPL) 100% $150 / $300 $400 / $800 $0 $5 0% 0% 0% 50% $8,800 / $17,600 $9,200 / $18,400 HF Silver AV87 POS Select ( % FPL) 100% $900 / $1,800 $1,300 / $2,600 $0 $5 0% 0% 0% 50% $8,800 / $17,600 $9,200 / $18,400 HF Silver AV73 POS Select ( % FPL) 100% $3,200 / $6,400 $4,600 / $9,200 $0 $50 0% 0% 0% 50% $8,800 / $17,600 $9,200 / $18,400 HF Silver POS Select HF Silver AV94 POS Select ( % FPL) 10% $0 / $0 $600 / $1,200 $0 $5 $60 $60 10% 50% $5,200 / $10,400 $12,700 / $25,400 HF Silver AV87 POS Select ( % FPL) 10% $250 / $500 $2,250 / $4,500 $0 $5 $60 $60 10% 50% $5,200 / $10,400 $12,700 / $25,400 HF Silver AV73 POS Select ( % FPL) 10% $2,100 / $4,200 $5,200 / $10,400 $0 $40 HF Silver POS Select % 50% $5,200 / $10,400 $12,700 / $25,400 HF Silver AV94 POS Select ( % FPL) 10% $0 / $0 $650 / $1,300 $0 $5 $50 $50 10% 50% $6,000 / $12,000 $12,000 / $24,000 HF Silver AV87 POS Select ( % FPL) 90% $350 / $700 $2,250 / $4,500 $0 $5 $50 $50 10% 50% $6,000 / $12,000 $12,000 / $24,000 HF Silver AV73 POS Select ( % FPL) 90% $2,500 / $5,000 $5,200 / $10,400 $0 $25 HF Silver POS Select % 50% $6,000 / $12,000 $12,000 / $24,000 HF Silver AV94 POS Select ( % FPL) 85% $0 / $0 $1,000 / $2,000 $0 15% 15% 15% 15% HF Silver AV87 POS Select ( % FPL) 85% $400 / $800 $2,250 / $4,500 $0 15% 15% 15% 15% HF Silver AV73 POS Select ( % FPL) HF Silver POS Select % $1,650 / $3,300 $4,500 / $9,000 $0 15% 15% 15% 15% HF Silver AV94 POS Select ( % FPL) 80% $200 / $400 $500 / $1,000 $0 20% 20% 20% 20% $250 Rx HF Silver AV87 POS Select ( % FPL) 80% $700 / $1,400 $1,250 / $2,500 $0 20% 20% 20% 20% $250 Rx HF Silver AV73 POS Select ( % FPL) 80% $2,500 / $5,000 $3,800 / $7,600 $0 20% 20% 20% 20% HF Silver POS Select HF Silver AV94 POS Select ( % FPL) 70% $0 / $0 $600 / $1,200 $0 $35 $50 $50 30% HF Silver AV87 POS Select ( % FPL) 70% $800 / $1,600 $1,500 / $3,000 $0 $35 $50 $50 30% HF Silver AV73 POS Select ( % FPL) 70% $3,000 / $6,000 $5,000 / $10,000 $0 $35 $50 $50 30% HF Silver POS Select HF Silver AV94 POS Select ( % FPL) 70% $0 / $0 $600 / $1,200 $0 30% 30% 30% 30% HF Silver AV87 POS Select ( % FPL) 70% $0 / $0 $2,000 / $4,000 $0 30% 30% 30% 30% HF Silver AV73 POS Select ( % FPL) 70% $1,300 / $2,600 $4,600 / $9,200 $0 30% 30% 30% 30% HF Silver POS Select HF Silver AV94 POS Select ( % FPL) 70% $0 / $0 $600 / $1,200 $0 30% 30% 30% 30% HF Silver AV87 POS Select ( % FPL) 70% $0 / $0 $2,000 / $4,000 $0 30% 30% 30% 30% HF Silver AV73 POS Select ( % FPL) 70% $1,200 / $2,400 $5,200 / $10,400 $0 30% 30% 30% 30% Page 4
5 2015 Individual PPO Plans Comparison of Benefits PPO HF Gold PPO Select (including 15 Routine Specialist Visit (including Behavioral 90% $1,500 / $3,000 $3,000 / $6,000 $0 10% 10% 10% 10% HF Gold PPO Select % $1,000 / $2,000 $2,500 / $5,000 $0 HF Gold PPO Select % $1,500 / $3,000 $4,000 / $8,000 $0 HF Gold PPO Select % $1,000 / $2,000 $6,350 / $12,700 $0 Visits 4+, 20% 20% 20% 20%, $350 for, $15 $30 $30 20%, $600/admission for Inpatient Care, : : : Copay applies to first 5 visits, then 20% : : : $20 $40 $40 20%, $875/admission for Inpatient Care, : : : Copay applies to first 3 visits, then 20% : : :, $150 for Specialty Imaging HF Gold PPO Select % $1,000 / $2,000 $2,900 / $5,800 $0 30% 30% 30% 30% HF Gold PPO Select % $1,000 / $2,000 $3,000 / $6,000 $0 $35 $50 $50 30%, : : : Copay applies to first 4 visits, then 30% : : : $0 for Diagnostic Labs HF Gold PPO Select % $1,000 / $2,000 $2,000 / $4,000 $0 50% 50% 50% 50% HF Silver PPO Select % $2,000 / $4,000 $4,500 / $9,000 $0 15% 15% 15% 15% HF Silver PPO Select % $2,500 / $5,000 $6,350 / $12,700 $0 20% 20% 20% 20% HF Silver PPO Select % $2,000 / $4,000 $4,600 / $9,200 $0 30% 30% 30% 30% HF Silver PPO Select % $2,000 / $4,000 $6,000 / $12,000 $0 30% 30% 30% 30% HF Silver PPO Select % $3,500 / $7,000 $6,350 / $12,700 $0 $35 $50 $50 30% HF Bronze PPO Select % $4,000 / $8,000 $6,350 / $12,700 $0 20% 20% 20% 20% HF Catastrophic PPO Select % $6,600 / $13,200 $6,600 / $13,200 $0 Visits 4+, 0% 0% 0% 0% 5-tier Formulary Single ( waived for Tiers 1-2) 10% after 50% after 20% after 0% after Calendar Year (separate from in-network OOP max.) 60% $3,000 / $6,000 $6,000 / $12,000 50% $2,000 / $4,000 $5,000 / $10,000 50% $3,000 / $6,000 $8,000 / $16,000 50% $2,000 / $4,000 $12,800 / $25,600 50% $2,000 / $4,000 $5,800 / $11,600 50% $2,000 / $4,000 $6,000 / $12,000 50% $2,000 / $4,000 $4,000 / $8,000 50% $8,000 / $16,000 $12,700 / $25,400 50% $13,200 / $26,400 $13,200 / $26,400 Page 5
6 2015 Individual PPO Plans Comparison of Benefits Cost-Share Reduction Variations PPO CSR (including 15 Routine PCP Office Visit Specialist Visit (including Behavioral Urgent Care 5-tier Formulary, Single ( waived for Tiers 1-2) Calendar Year (separate from in-network OOP max.) HF Silver PPO Select HF Silver AV94 PPO Select ( % FPL) 85% $0 / $0 $1,000 / $2,000 $0 15% 15% 15% 15% HF Silver AV87 PPO Select ( % FPL) 85% $400 / $800 $2,250 / $4,500 $0 15% 15% 15% 15% HF Silver AV73 PPO Select ( % FPL) HF Silver PPO Select % $1,650 / $3,300 $4,500 / $9,000 $0 15% 15% 15% 15% HF Silver AV94 PPO Select ( % FPL) 80% $200 / $400 $500 / $1,000 $0 20% 20% 20% 20% HF Silver AV87 PPO Select ( % FPL) 80% $700 / $1,400 $1,250 / $2,500 $0 20% 20% 20% 20% HF Silver AV73 PPO Select ( % FPL) 80% $2,500 / $5,000 $3,800 / $7,600 $0 20% 20% 20% 20% HF Silver PPO Select HF Silver AV94 PPO Select ( % FPL) 70% $0 / $0 $600 / $1,200 $0 30% 30% 30% 30% HF Silver AV87 PPO Select ( % FPL) 70% $0 / $0 $2,000 / $4,000 $0 30% 30% 30% 30% HF Silver AV73 PPO Select ( % FPL) 70% $1,200 / $2,400 $5,200 / $10,400 $0 30% 30% 30% 30% HF Silver PPO Select HF Silver AV94 PPO Select ( % FPL) 70% $0 / $0 $600 / $1,200 $0 $35 $50 $50 30% HF Silver AV87 PPO Select ( % FPL) 70% $800 / $1,600 $1,500 / $3,000 $0 $35 $50 $50 30% HF Silver AV73 PPO Select ( % FPL) 70% $3,000 / $6,000 $5,000 / $10,000 $0 $35 $50 $50 30% HF Silver PPO Select HF Silver AV94 PPO Select ( % FPL) 70% $0 / $0 $600 / $1,200 $0 30% 30% 30% 30% HF Silver AV87 PPO Select ( % FPL) 70% $0 / $0 $2,000 / $4,000 $0 30% 30% 30% 30% HF Silver AV73 PPO Select ( % FPL) 70% $1,300 / $2,600 $4,600 / $9,200 $0 30% 30% 30% 30% $250 Rx $250 Rx Page 6
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