Summary of Benefits and Coverage:
What the Plan Covers and Costs

HIP Prime POS Base | HIP Prime POS with Rx

Benefits Summary: HIP Prime POS

Medical Care  In-Network Cost Out-of-Network Cost
PCP office visit $5 copay Covered 70% after deductible
Well child care $0 copay Covered 70% after deductible
Specialist office visit $10 copay You pay the difference between the provider’s fee and HIP’s reimbursement. Covered 70% after deductible.
Diagnostic lab/X-ray Included in PCP or specialist copay
Routine physical exam $0
Outpatient mental health $10 copay
Urgent care PCP or specialist copay
Ambulatory surgery $0
Ambulance $0
Inpatient care $100 copay
Anesthesia Included in hospital copay
Emergency room $50 copay (waived if admitted) $50 copay (waived if admitted)

Additional Cost Sharing In-Network Cost Out-of-Network Cost
Annual deductible $0 $750 individual/$2,250 family
Annual coinsurance $0 HIP will cover 70% of the Fee Schedule
Coinsurance maximum $0 $3,000 individual/$9,000 family
Out-of-network annual maximum Not applicable Unlimited
Out-of-network lifetime maximum Not applicable Unlimited

Additional Riders

City employees can add the following benefit to their HIP Prime POS plan through a payroll deduction:

Prescription drugs ($10 generic and $35 brand drugs from network retail drug stores). Formulary copays are reduced by 50% when utilizing the Mail Order Pharmacy Service for home delivery.

Note: Durable medical equipment and private duty nursing are part of the base POS plan. No rider is needed.