| 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 |
$4,000 for single $8,000 for family |
$5,000 for single $10,000 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 |
$2,000 for single $4,000 for family |
$1,000 for Single $2,000 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 | $30 copay after deductible met | $25 per visit | $25 per visit | $25 per visit | 20% coinsurance after deductible |
| Emergency Room |
$100 copay after deductible is met |
$150 / visit (waived if admitted) |
$150 / visit (waived if admitted) |
$150 / visit (waived if admitted) |
$150 / visit (waived if admitted) |
| Hospitalization | Covered after deductible | Covered after deductible | Covered in full | $500 per admission | 20% coinsurance |
| Day Surgery | Covered after deductible | Covered after deductible | 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 | Level 1: $30 copay after deductible is met Level 2: $50 copay after deductible is met |
$25 per visit | $25 per visit | $25 per visit | 20% coinsurance after deductible |
| Office Visits – Specialist | Level 1: $30 copay after deductible is met Level 2: $50 copay after deductible is met |
$25 per visit – referral req | $25 per visit – referral req | $25 per visit | 20% coinsurance after deductible |
| Diagnostic Test, Lab work | Covered after deductible | Covered after deductible | Covered in full | Covered in full | 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 | Level 1: $30 copay after deductible is met Level 2: $50 copay after deductible is met |
$25 per visit | $25 per visit | $25 per visit | 20% coinsurance after deductible |
| Hospitalization/Delivery | Covered after deductible | Covered 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 | Covered after deductible | Covered in full | $500 / admission | 20% coinsurance after deductible |
| Outpatient | $30 copay once deductible is met | $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** |
|---|---|---|---|---|---|
| Habilitative/Rehabilitative Services (Short-term physical therapy, Occupational therapy) | $30 copay per visit-after deductible is met (60 visits per type of therapy | Covered after deductible met - 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 | $30 copay per visit, after deductible is met - unlimited visits | Covered after deductible met - 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 | Covered after deductible met - 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 | Covered 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 | 30% 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 for each impaired ear. | No charge. Limited to $2,000 per hearing aid every 36 months, for each hearing impaired ear. Once the limit is met there is no additional coverage. | No charge. Limited to $2,000 per hearing aid every 36 months, for each hearing impaired ear. Once the limit is met there is no additional coverage. | No charge. Limited to $2,000 per hearing aid every 36 months, for each hearing impaired ear. Once the limit is met there is no additional coverage. | 20% coinsurance after deductible. No charge. Limited to the same $2,000 per hearing aid every 36 months, for each hearing impaired ear. |
| Chiropractic and Acupuncture Services | $30 copay per visit, after deductible is met - unlimited visits | $25 per visit -unlimited visits | $25 per visit - unlimited visits | $25 per visit -unlimited visits | 20% coinsurance -unlimited visits |
| Covered Services |
Best Buy HSA HMO* |
Best Buy HMO |
HMO |
PPO in network |
PPO out-of-network** |
|---|---|---|---|---|---|
|
Prescriptions (Retail) (up to a 30-day supply) |
After deductible met
|
|
|
|
Reimbursable at in network level |
|
Prescriptions (Retail) (up to a 90-day supply) |
After deductible met
|
|
|
|
Reimbursable at in network level |
|
Mail Order Rx Drugs (up to a 90-day supply) |
After deductible met
|
|
|
|
Reimbursable at in network level |
|
Specialty Rx Drugs (up to a 30-day supply) |
After deductible met
|
|
|
|
Not Covered |
Prescriptions Administered by OptumRx.com (855-5546-3439) BIN:61001, PCN: IRX, Group: EDHEALTH
*Deductible applies 1st for all services except Annual Preventative.
**Deductible applies 1st, then 20% co-insurance for most services.
***Routine Physical Exams (including most preventative screenings), Well-Child Care, Preventative Immunizations, Preventative, Mammograms, Preventative Colonoscopies (Colonoscopies which include surgical removal will not be considered preventative and will be subject to the copay, deductible and/or coinsurance.