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Benefit Schedules: HMO Plans | PPO $500/$1,000 | PPO $2,500/$5,000 | HSA Eligible
Arizona Medical Insurance > HealthNet of Arizona > HSA Eligible Plans
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The information below shows the high-deductible PPO plans that can be used in conjunction with a Health Savings Account.
| BENEFITS | PPO $1,750/$3,500/100/50% |
PPO $2,600/$5,150/100/50% |
PPO $2,600/$5,150/80/50% |
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| Deductible 1 (includes medical and prescription; per calendar year) |
In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network |
| $1,750 Individual $3,500 Family |
$3,500 Individual $7,000 Family |
$2,600 Individual $5,150 Family |
$5,200 Individual $10,300 Family |
$2,600 Individual $5,150 Family |
$5,200 Individual $10,300 Family |
|
| Maximum lifetime benefits (in- and out-of-network combined) |
$5,000,000 | $5,000,000 | $5,000,000 | |||
| Out-of-pocket maximum, excluding deductible | $0 Individual $0 Family |
$6,500 Individual $13,000 Family |
$0 Individual $0 Family |
$4,800 Individual $9,700 Family |
$2,500 Individual $5,000 Family |
$4,800 Individual $9,700 Family |
| Inpatient hospital services (including physician, facility and surgery charges) |
0%, Subject to Deductible | 50%, Subject to Deductible | 0%, Subject to Deductible | 50%, Subject to Deductible |
20%, Subject to Deductible | 50%, Subject to Deductible |
| Outpatient hospital services/ ambulatory surgical center services |
0%, Subject to Deductible | 50%, Subject to Deductible | 0%, Subject to Deductible | 50%, Subject to Deductible |
20%, Subject to Deductible | 50%, Subject to Deductible |
| Office visits | 0%, Subject to Deductible | 50%, Subject to Deductible | 0%, Subject to Deductible | 50%, Subject to Deductible |
20%, Subject to Deductible | 50%, Subject to Deductible |
| Preventive care (routine physicals, annual GYN exams, well-baby care, immunizations and vision and hearing screenings) No charge for first $300 per member per calendar year, does not apply to ages 0 through 4. |
0%, Subject to
Deductible No charge for first $300. |
50%, Subject to Deductible | 0%, Subject to
Deductible No charge for first $300. |
50%, Subject to Deductible |
20%, Subject to
Deductible No charge for first $300. |
50%, Subject to Deductible |
| Outpatient laboratory and X-ray services | 0%, Subject to Deductible | 50%, Subject to Deductible | 0%, Subject to Deductible | 50%, Subject to Deductible |
20%, Subject to Deductible | 50%, Subject to Deductible |
| Outpatient imaging and testing services (including but not limited to CT scans, MRIs, MRAs and PET/SPECT scans) | 0%, Subject to Deductible | 50%, Subject to Deductible | 0%, Subject to Deductible | 50%, Subject to Deductible |
20%, Subject to Deductible | 50%, Subject to Deductible |
| Other Benefits | ||||||
| Prenatal and postpartum care (office visit copayment waived after diagnosis of pregnancy is confirmed) | Not covered | Not covered | Not covered | |||
| 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.) |
Not covered except for complications of pregnancy | Not covered except for complications of pregnancy | Not covered except for complications of pregnancy | |||
| Outpatient prescription drugs (up to a 31-day supply. Quantity limits may apply. Out-ofnetwork coverage is for out-of-area emergencies only.) |
0%, Subject to Deductible | Out-of-area emergencies only |
0%, Subject to Deductible | Out-of-area emergencies only |
Tier 1: $15 Tier 2: $40 Tier 3: $75 Tier 4: $100 Subject to Deductible* |
Out-of-area emergencies only |
| 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.) |
0%, Subject to Deductible | Out-of-area emergencies only |
0%, Subject to Deductible | Out-of-area emergencies only |
Tier 4: $100 Subject to Deductible* |
Out-of-area emergencies only |
| Emergency room services | 0%, Subject to Deductible | 0%, Subject to Deductible | 0%, Subject to Deductible | 0%, Subject to Deductible | 20%, Subject to Deductible | 20%, Subject to Deductible |
| Ambulance services (medical emergencies only) |
0%, Subject to Deductible | 0%, Subject to Deductible | 0%, Subject to Deductible | 0%, Subject to Deductible | 20%, Subject to Deductible | 20%, Subject to Deductible |
| Urgent care services | 0%, Subject to Deductible | 50%, Subject to Deductible | 0%, Subject to Deductible | 50%, Subject to Deductible |
20%, Subject to Deductible | 50%, Subject to Deductible |
| Rehabilitative services (limited to short-term, maximum of 60 days per calendar year, all therapies combined) |
0%, Subject to Deductible | 50%, Subject to Deductible | 0%, Subject to Deductible | 50%, Subject to Deductible |
20%, Subject to Deductible | 50%, Subject to Deductible |
| Skilled nursing facility services (limited to 60 days per calendar year) | 0%, Subject to Deductible | 50%, Subject to Deductible | 0%, Subject to Deductible | 50%, Subject to Deductible |
20%, Subject to Deductible | 50%, Subject to Deductible |
| Mental health services (outpatient: limited to short-term evaluation or crisis intervention. Maximum of 10 visits per calendar year.) |
Inpatient: Not Covered Outpatient: 0%, Subject to Deductible |
Inpatient: Not Covered Outpatient: 50%, Subject to Deductible |
Inpatient: Not Covered Outpatient: 0%, Subject to Deductible |
Inpatient: Not Covered Outpatient: 50%, Subject to Deductible |
Inpatient: Not Covered Outpatient: 20%, Subject to Deductible |
Inpatient: Not Covered Outpatient: 50%, Subject to Deductible |
1 There are no individual deductibles with the family plan designs. This benefit chart is a summary only. For benefit details, please see your Schedule of Benefits and Policy. |
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