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Gold Plans

  HMO Hybrid 23   Standard HMO Copayment 20
In-Network Deductible   Individual: $1,200
Family: $2,400		   Individual: $600
Family: $1,200
Preventive Care   $0   $0
Office Visit   $25   $25*
Doctor on Demand Visits   $0   $25*
Specialist Visit   $50   $40*
Prescription Drugs   Tier 1: $1
Tier 2: 20%
Tier 3: 50%		   Tier 1: $10
Tier 2: $35
Tier 3: $70
Urgent Care   $75   $60*
Emergency Room   20%*   $150*
Inpatient Hospital   20%*   $1,000*
Outpatient Surgery   20%*   $100*
Plan Documents   Summary of Benefits & Coverage
Health Plan Contract		   Summary of Benefits & Coverage
Health Plan Contract

*Subject to Deductible

 

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