HMO Federally-Qualified Plans (F-Plans)
The plans listed below are federally-qualified mandated plans for use with:
- Groups with ten (10) or more employees after the group's plan renewal on or after 12/1/2010; until that renewal occurs, group participants should refer to the standard HMO Plan Benefits information
- Groups with two (2) to nine (9) employees that have opted for the federally-qualified mandated plans; groups with two (2) to nine (9) employees that have not opted for the federally-qualified mandated plans should refer to the standard HMO Plan Benefits
Please contact your Network Health Account Manager for more information.
| Plan Name | Deductible | Coinsurance | Out of Pocket | Office Visit Copay | Prescription Benefits | |||
| Single | Family | Member | Single | Family | PCP | Specialist | ||
| F-HMO1 | N/A | N/A | N/A | N/A | N/A | $15 | $30 | 50008 - Standard 5 Tier $10/25/50/50/80 50070 - Standard 5 Tier $20/40/60/60/100 52018 - $150 Deductible then $10/25/50/50/80 52028 - $250 Deductible then $10/25/50/50/80 52058 - $500 Deductible then $10/25/50/50/80 70000 - 50% Co-insurance |
| F-HMO2 | $250 | $500 | 20% | $1500 | $3000 | $20 | $40 | |
| F-HMO3 | $250 | $500 | 20% | $2500 | $5000 | $25 | $50 | |
| F-HMO4 | $250 | $500 | 20% | $3000 | $6000 | $25 | $50 | |
| F-HMO5 | $500 | $1500 | 20% | $3500 | $7000 | $25 | $50 | |
| F-HMO6 | $750 | $2250 | 20% | $4000 | $8000 | $25 | $50 | |
| F-HMO7 | $1000 | $3000 | 20% | $4500 | $9000 | $30 | $60 | |
| F-HMO8 | $2000 | $6000 | 20% | $5000 | $10000 | $30 | $60 | |
| F-HMO $20 COPAY | N/A | N/A | N/A | $2000 | $4000 | $20 | $40 | |
| F-HMO $30 COPAY | N/A | N/A | N/A | $3000 | $6000 | $30 | $60 | |
| F-CDHMO1 | $1500 | $3000 | 0% | $1500 | $3000 | D/C | D/C | |
| F-CDHMO2 | $2500 | $5000 | 0% | $2500 | $5000 | D/C | D/C | |
| F-CDHMO3 | $3500 | $7000 | 0% | $3500 | $7000 | D/C | D/C | |
| F-H250 COCHOICE | $250 | $500 | 20% | $2250 | $4500 | $30 | $60 | |
| F-H500 COCHOICE | $500 | $1000 | 20% | $2500 | $5000 | $30 | $60 | |
| F-H750 COCHOICE | $750 | $1500 | 20% | $2750 | $5500 | $30 | $60 | |
| F-H1000 COCHOICE | $1000 | $2000 | 20% | $3000 | $6000 | $30 | $60 | |
| F-H1000 EXCOCHOICE | $1000 | $2000 | 30% | $2500 | $5000 | $25 | $50 | |
| F-H1500 COCHOICE | $1500 | $3000 | 20% | $3500 | $7000 | $30 | $60 | |
| F-H2000 COCHOICE | $2000 | $4000 | 20% | $4000 | $8000 | $30 | $60 | |
| F-H2500 COCHOICE | $2500 | $5000 | 20% | $4500 | $9000 | $30 | $60 | |
| F-H3000 COCHOICE | $3000 | $6000 | 20% | $5000 | $10000 | $30 | $60 | |
| F-H3500 COCHOICE | $3500 | $7000 | 20% | $5500 | $11000 | $30 | $60 | |
| F-H4000 COCHOICE | $4000 | $8000 | 20% | $6000 | $12000 | $30 | $60 | |
| F-H4500 COCHOICE | $4500 | $9000 | 20% | $6500 | $13000 | $30 | $60 | |
| F-H5000 COCHOICE | $5000 | $10000 | 20% | $7000 | $14000 | $30 | $60 | |
| F-HSAH1500 - 0% | $1500 | $3000 | 0% | $1500 | $3000 | D | D | 100% HSA HMO |
| F-HSAH2000 - 0% | $2000 | $4000 | 0% | $2000 | $4000 | D | D | |
| F-HSAH2500 - 0% | $2500 | $5000 | 0% | $2500 | $5000 | D | D | |
| F-HSAH3000 - 0% | $3000 | $6000 | 0% | $3000 | $6000 | D | D | |
| F-HSAH3500 - 0% | $3500 | $7000 | 0% | $3500 | $7000 | D | D | |
| F-HSAH4000 - 0% | $4000 | $8000 | 0% | $4000 | $8000 | D | D | |
| F-HSAH4500 - 0% | $4500 | $9000 | 0% | $4500 | $9000 | D | D | |
| F-HSAH5000 - 0% | $5000 | $10000 | 0% | $5000 | $10000 | D | D | |
| F-HSAH1500 - 10% | $1500 | $3000 | 10% | $2000 | $4000 | D/C | D/C | 50014 - 5 Tier $10/25/50/50/80 50200 - 5 Tier $20/40/60/60/100 50500 - Deductible then 50% Co-insurance |
| F-HSAH2000 - 10% | $2000 | $4000 | 10% | $2500 | $5000 | D/C | D/C | 50012 - 5 Tier $10/25/50/50/80 50202 - 5 Tier $20/40/60/60/100 50502 - Deductible then 50% Co-insurance |
| F-HSAH2500 - 10% | $2500 | $5000 | 10% | $3000 | $6000 | D/C | D/C | 50016 - 5 Tier $10/25/50/50/80 50204 - 5 Tier $20/40/60/60/100 50504 - Deductible then 50% Co-insurance |
| F-HSAH3000 - 10% | $3000 | $6000 | 10% | $3500 | $7000 | D/C | D/C | 50010 - 5 Tier $10/25/50/50/80 50206 - 5 Tier $20/40/60/60/100 50506 - Deductible then 50% Co-insurance |
| F-HSAH1500 - 20% | $1500 | $3000 | 20% | $2500 | $5000 | D/C | D/C | 50018 - 5 Tier $10/25/50/50/80 50216 - 5 Tier $20/40/60/60/100 50508 - Deductible then 50% Co-insurance |
| F-HSAH2000 - 20% | $2000 | $4000 | 20% | $3000 | $6000 | D/C | D/C | 50020 - 5 Tier $10/25/50/50/80 50218 - 5 Tier $20/40/60/60/100 50510 - Deductible then 50% Co-insurance |
| F-HSAH2500 - 20% | $2500 | $5000 | 20% | $3500 | $7000 | D/C | D/C | 50022 - 5 Tier $10/25/50/50/80 50220 - 5 Tier $20/40/60/60/100 50512 - Deductible then 50% Co-insurance |
| F-HSAH3000 - 20% | $3000 | $6000 | 20% | $4000 | $8000 | D/C | D/C | 50024 - 5 Tier $10/25/50/50/80 50222 - 5 Tier $20/40/60/60/100 50514 - Deductible then 50% Co-insurance |
| F-HSAH3500 - 20% | $3500 | $7000 | 20% | $4500 | $9000 | D/C | D/C | 50046 - 5 Tier $10/25/50/50/80 50224 - 5 Tier $20/40/60/60/100 50524 - Deductible then 50% Co-insurance |
| F-HSAH4000 - 20% | $4000 | $8000 | 20% | $5000 | $10000 | D/C | D/C | 50048 - 5 Tier $10/25/50/50/80 50226 - 5 Tier $20/40/60/60/100 50526 - Deductible then 50% Co-insurance |
| F-HSAH4500 - 20% | $4500 | $9000 | 20% | $5500 | $11000 | D/C | D/C | 50050 - 5 Tier $10/25/50/50/80 50228 - 5 Tier $20/40/60/60/100 50528 - Deductible then 50% Co-insurance |
| F-HSAH5000 - 20% | $5000 | $10000 | 20% | $5600 | $11200 | D/C | D/C | 50052 - 5 Tier $10/25/50/50/80 50230 - 5 Tier $20/40/60/60/100 50530 - Deductible then 50% Co-insurance |