| 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
|