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HDHMO HSA-Qualified 44

In-Network Deductible

Individual: $6,250

Family: $12,500

Preventive Care**

$0

Office Visit

30%*

Doctor on Demand Visits

0%*

Specialist Visit

30%*

Prescription Drugs**

Tier 1: 50%*

Tier 2: 50%*

Tier 3: 50%*

Urgent Care

30%*

Emergency Room

30%*

Inpatient Hospital

30%*

Outpatient Surgery

30%*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

Standard HDHMO HSA-Qualified 40

In-Network Deductible

Individual: $6,100

Family: $12,200

Preventive Care**

$0

Office Visit

50%*

Doctor on Demand Visits

$50%*

Specialist Visit

50%*

Prescription Drugs**

Tier 1: $10*

Tier 2: $35*

Tier 3: $70*

Urgent Care

$50%*

Emergency Room

50%*

Inpatient Hospital

50%*

Outpatient Surgery

50%*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

HDHMO HSA-Qualified 45

In-Network Deductible

Individual: $6,900

Family: $13,800

Preventive Care**

$0

Office Visit

0%*

Doctor on Demand Visits

0%*

Specialist Visit

0%*

Prescription Drugs**

Tier 1: $0%*

Tier 2: 0%*

Tier 3: 0%*

Urgent Care

0%*

Emergency Room

0%*

Inpatient Hospital

0%*

Outpatient Surgery

0%*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

Standard HDHMO Non HSA-Qualified 60

In-Network Deductible

Individual: $4,700

Family: $9,400

Preventive Care**

$0

Office Visit

$50 Copayment*

First 3 visits to a PCP/Specialist are not subject to the deductible

Doctor on Demand Visits

$50*

Specialist Visit

$75 Copayment*

First 3 visits to a PCP/Specialist are not subject to the deductible

Prescription Drugs**

Tier 1: $10*

Tier 2: $35*

Tier 3: $80*

Urgent Care

$75*

Emergency Room

$500*

Inpatient Hospital

$1,500*

Outpatient Surgery

$150*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

*Subject to deductible

**Preventive Care and Preventive Drugs Are Not Subject to Deductible

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