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  HMO Hybrid 13   Standard HMO Copayment 10   HMO Copayment 14
In-Network Deductible   Individual: $200 | Family: $400   Individual: $0 | Family: $0   Individual: $0 | Family: $0
Preventive Care   $0   $0   $0
Office Visit   $15   $15   $0
Live Video Doctor Visits   $15   $15   $0
Specialist Visit   $20   $35   $25
Prescription Drugs   Tier 1: $1
Tier 2: 10%
Tier 3: 40%
  Tier 1: $10
Tier 2: $30
Tier 3: $60
  Tier 1: $5
Tier 2: $15
Tier 3: $45
Urgent Care   $30   $55   $40
Emergency Room   10%   $100   $200
Inpatient Hospital   10%   $500   $250
Outpatient Surgery   10%   $100   $100
Plan Documents   Summary of Benefits & Coverage
Health Plan Contract
  Summary of Benefits & Coverage
Health Plan Contract
  Summary of Benefits & Coverage
Health Plan Contract

 

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