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General Information: Index | Exclusions & Limitations | Locate Providers | Electronic Application
Benefit Schedules: HMO Plans | PPO $500/$1,000 | PPO $2,500/$5,000 | HSA Eligible
Arizona Medical Insurance > HealthNet of Arizona > HMO Plans
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| BENEFITS | HMO $0 DEDUCTIBLE/70% COINSURANCE | HMO $1,000 DEDUCTIBLE/70% COINSURANCE |
| Deductible (per calendar year) |
None | $1,000 Single/$2,000 Family |
| Maximum lifetime benefits (in- and out-of-network combined) |
Unlimited | Unlimited |
| Out-of-pocket maximum, excluding deductible and copays for office visits and pharmacy benefits | $7,500 Single/$15,000 Family | $3,500 Single/$7,000 Family |
| Inpatient hospital services (including physician, facility and surgery charges) |
$400 Copay/Admit Plus 30% | 30%, Subject to Deductible |
| Outpatient hospital services/ ambulatory surgical center services |
$400 Copay/Admit Plus 30% | 30%, Subject to Deductible |
| Office visits | ||
| Primary care physician | $30 Copay/Visit | $25 Copay/Visit |
| Specialist | $45 Copay/Visit | $50 Copay/Visit |
| Preventive care (routine physicals, annual GYN exams, well-baby care, immunizations and vision and hearing screenings) |
$30 Copay/PCP Visit $45 Copay/Specialist Visit |
$25 Copay/PCP Visit $50 Copay/Specialist Visit |
| Outpatient laboratory and X-ray services | ||
| Performed at a physician’s office | 30% | No Charge |
| Performed at an independent, non-hospital affiliated lab facility* | 30% | No Charge |
| Performed at a hospital | $400 Copay/Visit Plus 30% | $100 Copay/Visit |
| Outpatient imaging and testing services (including but not limited to CT scans, MRIs, MRAs and PET/SPECT scans) | ||
| Performed at a physician’s office | 30% | $25 Copay/Visit |
| Performed at an independent, non-hospital affiliated lab facility* | 30% | $25 Copay/Visit |
| Performed at a hospital | $400 Copay/Visit Plus 30% | $200 Copay/Visit |
| Other Benefits | ||
| Prenatal and postpartum care (office visit copayment waived after diagnosis of pregnancy is confirmed) | $30 Copay/PCP Visit Covered after 12 months of enrollment |
$25 Copay/PCP Visit Covered after 12 months of enrollment |
| Maternity care (normal maternity deliveries are covered if the delivery occurs after the member’s contract has been in force for 21 months or longer. Complications of pregnancy are covered regardless of the delivery date.) |
$400 Copay/Visit Plus 30% | 30%, Subject to Deductible |
| Outpatient prescription drugs (up to a 31-day supply. Quantity limits may apply. Out-of-network coverage is for out-of-area emergencies only.) |
Tier 1: $10 Copay/Prescription or Refill Tier 2: $60 Copay/Prescription or Refill Tier 3: $90 Copay/Prescription or Refill Tier 4: $120 Copay/Prescription or Refill |
Tier 1: $15 Copay/Prescription or Refill Tier 2: $40 Copay/Prescription or Refill Tier 3: $75 Copay/Prescription or Refill Tier 4: $100 Copay/Prescription or Refill |
| Self-injectable drugs (tier 2 copayment will apply to preferred insulin vials. Quantity limits may apply. Out-ofnetwork coverage is for out-of-area emergencies only.) |
Tier 4: $120 Copay/Prescription or Refill | Tier 4: $100 Copay/Prescription or Refill |
| Emergency room services (copayment waived if admitted, inpatient hospital benefit will then apply) | $400 Copay/Visit Plus 30% | $150 Copay/Visit |
| Ambulance services (medical emergencies only) |
30% | No Charge |
| Urgent care services | 30% | $60 Copay/Visit |
| Rehabilitative services (limited to short-term, maximum of 60 days per calendar year, all therapies combined) |
Inpatient: $400 Copay/Admit Plus 30% Outpatient: 30% |
Inpatient: 30%, Subject to Deductible Outpatient: $50 Copay/Visit |
| Skilled nursing facility services (limited to 60 days per calendar year) | $400 Copay/Admit Plus 30% | 30%, Subject to Deductible |
| Chiropractic services (limited to 12 medically necessary visits per calendar year. Additional discounts available through the Well Rewards Program.) |
$45 Copay/Visit | $50 Copay/Visit |
| Mental health services (outpatient: limited to short-term evaluation or crisis intervention. Maximum of 10 visits per calendar year.) |
Inpatient: Not Covered Outpatient: $45 Copay/Individual Visit; $20 Copay/Group Visit |
Inpatient: Not Covered Outpatient: $25 Copay/Individual Visit; $12.50 Copay/Group Visit |
| *Some facilities are affiliated with a hospital. You will be charged a higher copay for services rendered at a hospital-affiliated facility. Contact the place of service for more information or our Customer Contact Center at 1-888-463-4875. | ||
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