| 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: $70*
|
|
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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