450A HIP POS
HIP Prime Network · out-of-network covered (80th %ile UCR)
Gated POS — $0 in-network deductible with $20/$40 copays, $500 inpatient copay, 3-tier Rx ($15/$35/$75); out-of-network covered at 50% after a $2,500/$5,000 deductible, reimbursed at the 80th percentile UCR. $6,600/$13,200 in-network out-of-pocket max.
Monthly premiums
- Member
- $3,621.00/mo
- Member & Spouse
- $6,533.00/mo
- Member & Children
- $6,533.00/mo
- Member & Family
- $10,331.00/mo
The only 450A EmblemHealth option with out-of-network coverage — $0 in-network deductible, $20/$40 copays
Plan details
- Deductible (Individual)
- $0
- Deductible (Family)
- $0
- Out-of-Pocket Max (Individual)
- $6,600
- Out-of-Pocket Max (Family)
- $13,200
- Coinsurance (In-Network)
- 0%
- Primary Care Copay
- $20
- Specialist Copay
- $40
- Urgent Care Copay
- $20
- ER Copay
- $100
Benefits
Deductible
$0 in-network
OON: $2,500 / $5,000
Max Out of Pocket
$6,600 / $13,200
In-network
Copay
$20 / $40 / $20
PCP / Specialist / Urgent Care
Coinsurance
0% in-network
OON: 50% after deductible, 80th %ile UCR
Emergency Room
$100 copay
Waived if admitted
Rx Coverage
$15 / $35 / $75
3 tiers; brand after $100 Rx deductible; mail order 90 days
Pregnancy
Covered
$20 visits; $500 delivery facility copay
Mental Health
Covered
$20 outpatient; $500 inpatient
Hospital Admission
$500 per admission
Preauthorization required
Referrals
Required
Gated POS — in-network care through your PCP
Dependents
To Age 26
Coverage
In + out of network
HIP Prime Network; OON reimbursed at 80th %ile UCR
Work Requirement
Work Required
Plan documents
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