Covered Services |
Best Buy HSA HMO* |
Best Buy HMO |
HMO |
PPO in network |
PPO out-of-network** |
---|---|---|---|---|---|
Provider Network | HPHC network | HPHC network | HPHC network | HPHC /United Health Care | Out-of-Network |
Out of Pocket Maximum |
$2,500 for single $5,000 for family |
$2,500 for single $5,000 for family |
$2,500 for single $5,000 for family |
$2,500 for single $5,000 for family |
$2,500 for single $5,000 for family |
Annual Deductible |
$1,600 for single $3,200 for family |
$500 for Single $1,000 for Family |
N/A | N/A |
$500 for Single $1,000 for Family |
Covered Services |
Best Buy HSA HMO* |
Best Buy HMO |
HMO |
PPO in network |
PPO out-of-network** |
---|---|---|---|---|---|
Urgent Care | Covered in full after deductible met | $25 per visit | $25 per visit | $25 per visit | 20% coinsurance after deductible |
Emergency Room |
Covered after deductible |
$150 / visit (waived if admitted) |
$150 / visit (waived if admitted) |
$150 / visit (waived if admitted( |
$150 / visit (waived if admitted) |
Hospitalization | Covered after deductible | $500 per admission after deductible | Covered in full | $500 / admission | 20% coinsurance |
Day Surgery | Covered after deductible | $250 per surgery after ded | Covered in full | $250 per surgery | 20% coinsurance after deductible |
Covered Services |
Best Buy HSA HMO* |
Best Buy HMO |
HMO |
PPO in network |
PPO out-of-network** |
---|---|---|---|---|---|
Preventive services*** | Covered in full | Covered in full | Covered in full | Covered in full | 20% coinsurance after deductible |
OBGYN visits | Covered after deductible | $25 per visit | $25 per visit | $25 per visit | 20% coinsurance after deductible |
Hearing Exam | Covered after deductible | $25 per visit | $25 per visit | $25 per visit | 20% coinsurance after deductible |
Allergy shots | Covered after deductible | $5 per visit | $5 per visit | $5 per visit | 20% coinsurance after deductible |
Covered Services |
Best Buy HSA HMO* |
Best Buy HMO |
HMO |
PPO in network |
PPO out-of-network** |
---|---|---|---|---|---|
Office Visits | Covered after deductible | $25 per visit | $25 per visit | $25 per visit | 20% coinsurance after deductible |
Office Visits – Specialist | Covered after deductible | $25 per visit – referral req | $25 per visit – referral req | $25 per visit | 20% coinsurance after deductible |
Diagnostic Test, Lab work | Covered after deductible | Deductible only | $25 per visit | $25 per visit | 20% coinsurance after deductible |
Eye Exam –HPHC network | Covered after deductible | $25 once every 12 months | $25 once every 12 months | $25 once every 12 months | 20% coinsurance after deductible |
High Tech Imaging |
Covered after deductible | $75 / max 2 payments per year | $75 / max 2 payments | $75 / max 2 payments | 20% coinsurance after deductible |
Covered Services |
Best Buy HSA HMO* |
Best Buy HMO |
HMO |
PPO in network |
PPO out-of-network** |
---|---|---|---|---|---|
Prenatal/Postnatal Care (routine) | Covered after deductible | Covered in full | Covered in full | Covered in full | 20% coinsurance after deductible |
Office Visits | Covered after deductible | $25 per visit | $25 per visit | $25 per visit | 20% coinsurance after deductible |
Hospitalization/Delivery | Covered after deductible | $500 / admission after deductible | Covered in full | $500 / admission | 20% coinsurance after deductible |
Covered Services |
Best Buy HSA HMO* |
Best Buy HMO |
HMO |
PPO in network |
PPO out-of-network** |
---|---|---|---|---|---|
Inpatient | Covered after deductible | $500 / admission after deductible | Covered in full | $500 / admission | 20% coinsurance after deductible |
Outpatient | Covered after deductible | $25 / visit | $25 / visit | $25 / visit | 20% coinsurance after deductible |
Covered Services |
Best Buy HSA HMO* |
Best Buy HMO |
HMO |
PPO in network |
PPO out-of-network** |
---|---|---|---|---|---|
Prescriptions (up to a 30-day supply) |
After deductible is met $15 , $30, $150 |
$15 – Tier I $30 – Tier II $50 – Tier III |
$15 – Tier I $30 – Tier II $50 – Tier III |
$15 – Tier I $30 – Tier II $50 – Tier III |
Reimbursable at in network level |
Mail Order Rx Drugs (up to a 90-day supply) |
After deductible is met $30 , $60, $150 |
$30 – Tier I $60 – Tier II $150 – Tier III |
$30 – Tier I $60 – Tier II $150 – Tier III |
$30 – Tier I $60 – Tier II $150 – Tier III |
Reimbursable at in network level |
Specialty Rx Drugs (up to a 30-day supply) |
After deductible is met $15 , $30, $150 |
$15 – Tier I $30 – Tier II $50 – Tier III |
$15 – Tier I $30 – Tier II $50 – Tier III |
$15 – Tier I $30 – Tier II $50 – Tier III |
Not Covered |
Covered Services |
Best Buy HSA HMO* |
Best Buy HMO |
HMO |
PPO in network |
PPO out-of-network** |
---|---|---|---|---|---|
Habilitative/Rehabilitative Services (Short-term physical therapy, Occupational therapy) | Covered after deductible 60 visits per type of therapy | $25 per visit – 60 visits per type of therapy | $25 per visit – 60 visits per type of therapy | $25 per visit –60 visits per type of therapy | 20% coinsurance –60 visits per type of therapy |
Speech therapy | Covered after deductible | $25 per visit – unlimited visits | $25 per visit – unlimited | $25 per visit – unlimited | 20% coinsurance – unlimited |
Rehab Hospital Care (Prior authorization required) | Covered after deductible -60 days per year | $500 per admission after deductible -60 days per year | Covered in full –60 days per year | $500 per admission -60 days per year | $500 per admission after deductible -60 days per year |
Skilled Nursing Care (Prior authorization required) |
Covered after deductible -100 days per year | $500 per admission after deductible -100 days per year | Covered in full-100 days per year | $500 per admission -100 days per year | $500 per admission after deductible -100 days per year |
Durable Medical Equipment (DME)/Prosthetics | 20% coinsurance after deductible | 20% coinsurance | 20% coinsurance | 20% coinsurance | 20% coinsurance after deductible |
Hearing Aids | Deductible, then no charge. Limited to $2,000 per hearing aid every 36 months | First $2,000 covered per ear every 36 months, 20% DME coinsurance after limit has been reached | First $2,000 covered per ear every 36 months, 20% DME coinsurance after limit has been reached | First $2,000 covered per ear every 36 months, 20% DME coinsurance after limit has been reached | 20% coinsurance after deductible |
Chiropractic and Acupuncture Services | Covered after deductible | $25 per visit -unlimited visits | $25 per visit - unlimited visits | $25 per visit -unlimited visits | 20% coinsurance -unlimited visits |
*Deductible applies 1st for all services except Annual Preventative.
**Deductible applies 1st, then 20% co-insurance for most services.