What the Plan Costs and Covers

Summary of Benefits and Coverage:

HIP FEHB High Option — HIP Prime HMO

If you have questions about your plan benefits or would like to request a free printed copy of the Summary of Benefits and Coverage (“SBC”), please call Customer Service at 1-800-447-8255, Monday to Friday, 8 am to 6 pm (closed on weekends.) If you have a hearing or speech impairment and use a TDD, call 711.

Benefits At-a-Glance: HIP FEHB High Option — HIP Prime HMO


High Option - In Network
Medical Care
PCP office visit $30 copay ($0 copay for dependent children to age 26)
Specialist office visit $50 copay ($0 copay for dependent children to age 26)
Preventive Care
Routine physical exam $0 copay
Well child care $0 copay
Women’s wellness services $0 copay
Other Services
Outpatient mental health $30 PCP copay or $30 specialist copay ($0 copay for dependent children to age 26)
Urgent care $30 copay ($0 copay for dependent children to age 26)
Ambulatory surgery $150 copay
Ambulance $0 copay
Prescription drugs $20 generic/$40 brand/$100 non-formulary copay $100 annual deductible for brand drugs only
Hospital Services
Inpatient care $0 copay
Anesthesia Included in hospital copay
Emergency room $200 copay (waived if admitted)

The chart above is a high level summary of benefits only. For complete details about the benefits available through this plan, please read the Federal RI 73-001. Coverage is subject to all terms, conditions, limitations and exclusions contained in [Federal RI 73-001].