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.
