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
Live Video Doctor Visits   $25   $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

 

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