through 4/01/08
First National Administrators
HIP HMO Rates
All plans come with preventive dental
(2007 PLAN #1)
Plan 1
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IN NETWORK - $30.00 PCP & $50 Specialist office visit co-pay
In patient Hospital,out patient surgery,outpatient facility servicess including lab,X-Rays,EKG,MRI, cat scans,SNF (30 day limit) are subject to a $3,000/$6,0000 deductible and 80%/20% coinsurance to $10,000/$20,000 max per year
Eyeglasses - $0 copay for i pair of eyeglasses,$25 copay for contacts every12 months
Alternative medicine - $20 copay - 12 combined visits of (nutritional,accupuncture and massage (5 visit limit)
$100.00 Emergency Room co-pay
OUT of NETWORK -$3000/$6000 deductible and 70%/30% coinsurance to $10000/$20000 maximum out of pocket
Rx card - None - NO DME - No Private Duty Nursing
2007 Plan 2
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$25 PCP Offive copay, $40 specialist copay, $500 Hospital copay,$75 Outpatient surgery,$100 ER copay, Rx - $20 Generic/$30 Brand/$50 Non-Formulary. Durable Medical Equipment - covered in full
Eyeglasses - $45 allowance every 24 months
2007 Plan 3
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$20 Office co-pay PCP or $30 Specialist
$500 Hospital co-pay,$75 Outpatient surgery
$50 Emergency Room co-pay
with Drug card - no Deductible $7 Generic/$30 Brand /$50 non formulary
2007 Plan 4
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IN NETWORK BENEFITS
$20 PCP Office Visit copay, $30 Specialist
$1000/$2000 In Network Deductible & 90% Coinsurance to $2500/$5000 per year for out of the office benefits such as Inpatient hospital, out patient surgery, facility services such as X Rays,MRI,cat scans
$50 Emergency room copay
OUT OF NETWORK BENEFITS
$2000/$4000 deductible, 70% coinsurance to $5000/$10000 maximum out of pocket
with Rx card $20.00 generic/$30.00 brand/$50 non formulary