| 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.