NHP Prime HMO Plans
Download this chart
for easy-to-compare information on all NHP Prime HMO plans. Click on Schedule of Benefits
(SOBs) or Summary of Benefits and Coverage (SBCs) below for more details on each plan.
Plan Name
Annual
Deductible
Annual Max
Out-of-Pocket
Office
Visit
Retail
Emergency Inpatient
Prescriptions Room
Admission
None
$1,500/$3,000
$25/$25 $15/$30/$50
$100
$250
None
$2,000/$4,000
$25/$40 $15/$30/$50
$150
$500
$500/$1,000
$1,500/$3,000
$20/$35 $15/$25/$45
(D) $100
(D) $0
$500/$1,000
$2,000/$4,000
$20/$20 $15/$25/$45
$100
(D) $0
$1,000/$2,000 $5,000/$10,000 $20/$35 $20/$30/$50
(D) $150
(D) $250
$500/$1,000
$5,000/$10,000 $30/$45 $25/$40/$60
(D) $250
(D) $500
$1,000/$2,000 $5,000/$10,000 $30/$45 $20/$30/$50
(D) $150
(D) $500
$1,500/$3,000 $5,000/$10,000 $25/$40 $15/$25/$50
(D) $150
(D) $250
(D) 30%
(D) 30%
(D) $350
(D) $1,000
NHP Prime HMO
PY 25/25*
SOB
SBC
NHP Prime HMO
PY 25/40*
SOB
SBC
NHP Prime HMO
500/1000 PY
20/35*
SOB
SBC
NHP Prime HMO
500/1000 PY
20/20
SOB
SBC
NHP Prime HMO
1000/2000 PY
20/35*
SOB
SBC
NHP Prime HMO
500/1000 PY
30/45*
SOB
SBC
NHP Prime HMO
1000/2000 PY
30/45*
SOB
SBC
NHP Prime HMO
1500/3000 PY
25/40*
SOB
SBC
NHP Prime HMO
500/1000 PY
20/35 - 30%*
SOB
SBC
NHP Prime HMO
2000/4000 PY
$500/$1,000
$3,000/$6,000
$15/
(D), then
$20/$35
50%/
(D), then 50%
$2,000/$4,000 $6,350/$12,700 $30/$50 $20/$40/$70
30/50*
SOB
SBC
NHP Prime HMO
1750/3500 PY
50/80*
SOB
SBC
$1,750/$3,500
Rx Deductible
$250/$500
(D)
$6,350/$12,700 $50/(D)
$
80
(RxD), then
$50/
(RxD), then
$85/
(RxD), then
$120
(D) $750
(D)
$1,000
*Plan is also available on a Calendar Year Benefit Period
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NHP Prime HMO HSA Plans
Plan Name
NHP Prime HMO
HSA 2000/4000
40/85*
SOB
Annual Max
Out-of-Pocket
Office
Visit
Retail
Prescriptions
Emergency
Room
Inpatient
Admission
$2,000/$4,000
Aggregate
$6,350/$12,700
Aggregate
(D)$40/
(D) $85
(D), then $50/
(D), then $80/
(D), then $120
(D) $750
(D) $1,000
$2,000/$4,000
Aggregate
$6,350/$12,700
Aggregate
(D)$50/(D)$75
(D), then $30/
(D), then
50%/ (D),
then 50%
(D) $750
(D) $1,000
SBC
NHP Prime HMO
HSA 2000/4000
50/75*
SOB
Annual
Deductible
SBC
*Plan is also available on a Calendar Year Benefit Period

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