| Standard HMO Copayment 10 |
|
In-Network Deductible
Individual: $0
Family: $0
|
|
Preventive Care
$0
|
|
Office Visit
$15
|
|
Doctor on Demand Visits
$15
|
|
Specialist Visit
$35
|
|
Prescription Drugs
Tier 1: $10
Tier 2: $30
Tier 3: $60
|
|
Urgent Care
$55
|
|
Emergency Room
$100
|
|
Inpatient Hospital
$500
|
|
Outpatient Surgery
$100
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|