Gold Plans

HMO Hybrid 23

In-Network Deductible

Individual: $1,200

Family: $2,400

Preventive Care

$0

Office Visit

$25

Doctor on Demand Visits

$0

Specialist Visit

$50

Prescription Drugs

Tier 1: $1

Tier 2: 20%

Tier 3: 50%

Urgent Care

$75

Emergency Room

20%*

Inpatient Hospital

20%*

Outpatient Surgery

20%*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

Standard HMO Copayment 20

In-Network Deductible

Individual: $600

Family: $1,200

Preventive Care

$0

Office Visit

$25*

Doctor on Demand Visits

$25*

Specialist Visit

$40*

Prescription Drugs

Tier 1: $10

Tier 2: $35

Tier 3: $70

Urgent Care

$60*

Emergency Room

$150*

Inpatient Hospital

$1,000*

Outpatient Surgery

$100*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

*subject to deductible