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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 > PPO $2,500 & $5,000 Deductible Plans
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| BENEFITS | PPO $2,500 Deductible, 80/60% Coinsurance |
PPO $5,000 Deductible, 80/60% Coinsurance |
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| Deductible (per calendar year) |
In-Network | Out-of-Network | In-Network | Out-of-Network |
| $2,500 Single/$5,000 Family | $5,000 Single/$10,000 Family | $5,000 Single/$10,000 Family | $10,000 Single/$20,000 Family | |
| Maximum lifetime benefits (in- and out-of-network combined) |
$5,000,000 | $5,000,000 | ||
| Out-of-pocket maximum, excluding deductible and copays | $3,000 Single $6,000 Family |
$6,000 Single $12,000 Family |
$3,000 Single $6,000 Family |
$6,000 Single $12,000 Family |
| Inpatient hospital services (including physician, facility and surgery charges) |
20%, Subject to Deductible | 40%, Subject to Deductible | 20%, Subject to Deductible | 40%, Subject to Deductible |
| Outpatient hospital services/ ambulatory surgical center services |
20%, Subject to Deductible | 40%, Subject to Deductible | 20%, Subject to Deductible | 40%, Subject to Deductible |
| Office visits | ||||
| Primary care physician | $30 Copay/Visit | 40%, Subject to Deductible | $30 Copay/Visit | 40%, Subject to Deductible |
| Specialist | $45 Copay/Visit | 40%, Subject to Deductible | $45 Copay/Visit | 40%, Subject to Deductible |
| Preventive care (routine physicals, annual GYN exams, well-baby care, immunizations and vision and hearing screenings) |
$30 Copay/PCP Visit $45 Copay/Specialist Visit |
40%, Subject to Deductible | $30 Copay/PCP Visit $45 Copay/Specialist Visit |
40%, Subject to Deductible |
| Outpatient laboratory/X-ray services | ||||
| Performed at a physician’s office | No Charge | 40%, Subject to Deductible | No Charge | 40%, Subject to Deductible |
| Performed at an independent, non-hospital affiliated lab facility* | No Charge | 40%, Subject to Deductible | No Charge | 40%, Subject to Deductible |
| Performed at a hospital | 20%, Subject to Deductible | 40%, Subject to Deductible | 20%, Subject to Deductible | 40%, Subject to Deductible |
| Outpatient imaging and testing services (including but not limited to CT scans, MRIs, MRAs and PET/SPECT scans) | ||||
| Performed at a physician’s office | 20%, Subject to Deductible | 40%, Subject to Deductible | 20%, Subject to Deductible | 40%, Subject to Deductible |
| Performed at an independent, non-hospital affiliated lab facility* | 20%, Subject to Deductible | 40%, Subject to Deductible | 20%, Subject to Deductible | 40%, Subject to Deductible |
| Performed at a hospital | 20%, Subject to Deductible | 40%, Subject to Deductible | 20%, Subject to Deductible | 40%, Subject to Deductible |
| Other Benefits | ||||
| Prenatal and postpartum care (office visit copayment waived after diagnosis of pregnancy is confirmed) | 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 | ||
| Outpatient prescription drugs (up to a 31-day supply. Quantity limits may apply. Out-ofnetwork coverage is for out-of-area emergencies only.) |
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 |
Out-of-area emergencies only |
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 |
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.) |
Tier 4: $100 Copay/Prescription or Refill | Out-of-area emergencies only |
Tier 4: $100 Copay/Prescription or Refill | Out-of-area emergencies only |
| Emergency room services | 20%, Subject to $150 Copay/Visit/waived if admitted | 20%, Subject to $150 Copay/Visit/waived if admitted | ||
| Ambulance services (medical emergencies only) |
20%, Subject to Deductible | 20%, Subject to Deductible | ||
| Urgent care services | $60 Copay/Visit | 40%, Subject to Deductible | $60 Copay/Visit | 40%, Subject to Deductible |
| Rehabilitative services (limited to short-term, maximum of 60 days per calendar year, all therapies combined) |
Inpatient: 20%, Subject to Deductible Outpatient: $45 Copay/Visit |
Inpatient: 40%, Subject to Deductible Outpatient: 40%, Subject to Deductible |
Inpatient: 20%, Subject to Deductible Outpatient: $45 Copay/Visit |
Inpatient: 40%, Subject to Deductible Outpatient: 40%, Subject to Deductible |
| Skilled nursing facility services (limited to 60 days per calendar year) | 20%, Subject to Deductible | 40%, Subject to Deductible | 20%, Subject to Deductible | 40%, 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: 20%, Subject to Deductible |
Inpatient: Not Covered Outpatient: 40%, Subject to Deductible |
Inpatient: Not Covered Outpatient: 20%, Subject to Deductible |
Inpatient: Not Covered Outpatient: 40%, Subject to Deductible |
*Some facilities are affiliated with a hospital. You will be charged a higher copay for services rendered at a hospital-affiliated facility. This benefit chart is a summary only. For benefit details, please see your Schedule of Benefits and Policy. |
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