| HMO Triple Zero 24 |
|
In-Network Deductible
Individual: $0
Family: $0
|
|
Preventive Care
$0
|
|
Office Visit
$0 EPC/$50 PCP
|
|
Doctor on Demand Visits
$0
|
|
Specialist Visit
$50
|
|
Prescriptions Filled at Preferred Pharmacies1
Tier 1: $0
Tier 2: $50
Tier 3: $80
|
|
Prescriptions Filled at Non-Preferred Pharmacies
Tier 1: 50%
Tier 2: 50%
Tier 3: 50%
|
|
Urgent Care
$100
|
|
Emergency Room
$500
|
|
Inpatient Hospital
$1,500
|
|
Outpatient Surgery
$250
|
|
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*
|
|
Prescriptions Filled at Preferred Pharmacies1
Tier 1: $10
Tier 2: $35
Tier 3: $70
|
|
Prescriptions Filled at Non-Preferred Pharmacies
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
|
Get a Quote
1The CDPHP® Preferred Rx Network includes pharmacies who have teamed up with us to keep costs low and quality high for CDPHP members. Learn more.
*subject to deductible