Plan details

HAP 250 HMO Henry Ford Choice

  • Overview
    Plan year
    2019
    Metal tier
    Platinum
    Annual deductible - individual
    $250
    Annual deductible - family
    $500
    Coinsurance
    0%
    Out-of-pocket limit - individual
    $1,500
    Out-of-pocket limit - family
    $3,000
    Primary doctor visit
    $20 copay
    Specialist visit
    $40 copay
    Telehealth
    $0 copay
    Urgent care centers
    $65 copay
  • Preventive care
    Periodic physical exam/immunizations
    Covered
    Well baby/child exams
    Covered
    Routine hearing and eye exams
    Covered
    Prenatal visits
    Covered
    Preventive related lab tests and x-rays
    Covered
    Periodic OB/GYN exams
    Covered
    Mammograms
    Covered
  • Outpatient services
    Primary doctor visit
    $20 copay
    Specialist visit
    $40 copay
    Diagnostic test (x-ray, lab)
    $30 copay
    Imaging (CT/PET scans, MRIs)
    Covered after deductible
    Outpatient surgery and related services
    Covered after deductible
    Chiropractic care (20 visit limit)
    $30 copay
  • Emergency
    Emergency room services
    $200 copay
    Urgent care centers
    $65 copay
    Emergency transport/ambulance (EMS)
    $100 copay
  • Inpatient services
    Inpatient hospital services
    Covered after deductible
    Labor and delivery
    Covered after deductible
  • Maternity
    Prenatal visits
    Covered
    Postnatal visits
    $40 copay
    Labor and delivery
    Covered after deductible
  • Mental health and substance abuse
    Inpatient services
    Covered after deductible
    Outpatient services
    $20 copay
  • Vision
    Pediatric vision hardware, for children 18 and under, is an Essential Health Benefit and part of all HAP health plans.

    While adult vision hardware is not covered by this plan, an in-network annual vision exam is covered for both adults and children.

    Included vision benefits for children:
    • One pair of eyeglasses every calendar year
    • Contact lenses once every calendar year instead of eyeglasses
    • Wide selection of collection frames and collection contact lenses
  • Prescription
    Generic copay
    $5 Copay ($15 non-preferred)
    Brand copay
    $30 Copay ($60 non-preferrred)
    Preferred specialty coinsurance
    20% coinsurance up to $200 maximum per prescription
    Non preferred specialty coinsurance
    50% coinsurance up to $500 maximum per prescription

HAP 250 HMO Henry Ford Choice

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