Plan details

HAP 0 PPO

  • Overview
    Plan year
    2019
    Metal tier
    Platinum
    Annual deductible - individual
    $0
    (In network)
    $3,000
    (Out of network)
    Annual deductible - family
    $0
    (In network)
    $6,000
    (Out of network)
    Coinsurance
    0%
    (In network)
    50%
    (Out of network)
    Out-of-pocket limit - individual
    $1,250
    (In network)
    None
    (Out of network)
    Out-of-pocket limit - family
    $2,500
    (In network)
    None
    (Out of network)
    Primary doctor visit
    $20 copay
    (In network)
    50% after deductible
    (Out of network)
    Specialist visit
    $40 copay
    (In network)
    50% after deductible
    (Out of network)
    Telehealth
    $0 copay
    (In network)
    Not covered
    (Out of network)
    Urgent care centers
    $65 copay
  • Preventive care
    Periodic physical exam/immunizations
    Covered
    (In network)
    Not Covered
    (Out of network)
    Well baby/child exams
    Covered
    (In network)
    Not Covered
    (Out of network)
    Routine hearing and eye exams
    Covered
    (In network)
    Not Covered
    (Out of network)
    Prenatal visits
    Covered
    (In network)
    Not Covered
    (Out of network)
    Preventive related lab tests and x-rays
    Covered
    (In network)
    Not Covered
    (Out of network)
    Periodic OB/GYN exams
    Covered
    (In network)
    Not Covered
    (Out of network)
    Mammograms
    Covered
    (In network)
    Not Covered
    (Out of network)
  • Outpatient services
    Primary doctor visit
    $20 copay
    (In network)
    50% after deductible
    (Out of network)
    Specialist visit
    $40 copay
    (In network)
    50% after deductible
    (Out of network)
    Diagnostic test (x-ray, lab)
    $30 copay
    (In network)
    50% after deductible
    (Out of network)
    Imaging (CT/PET scans, MRIs)
    Covered
    (In network)
    50% after deductible
    (Out of network)
    Outpatient surgery and related services
    Covered
    (In network)
    50% after deductible
    (Out of network)
    Chiropractic care (20 visit limit)
    $30 copay
    (In network)
    50% after deductible
    (Out of network)
  • Emergency
    Emergency room services
    $200 copay
    Urgent care centers
    $65 copay
    Emergency transport/ambulance (EMS)
    $100 copay
  • Inpatient services
    Inpatient hospital services
    Covered
    (In network)
    50% after deductible
    (Out of network)
    Labor and delivery
    Covered
    (In network)
    50% after deductible
    (Out of network)
  • Maternity
    Prenatal visits
    Covered
    (In network)
    Not Covered
    (Out of network)
    Postnatal visits
    $40 copay
    (In network)
    50% after deductible
    (Out of network)
    Labor and delivery
    Covered
    (In network)
    50% after deductible
    (Out of network)
  • Mental health and substance abuse
    Inpatient services
    Covered
    (In network)
    50% after deductible
    (Out of network)
    Outpatient services
    $20 copay
    (In network)
    50% after deductible
    (Out of network)
  • 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
    $8 Copay ($20 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 0 PPO

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