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HMO Hybrid 13

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In-Network Deductible
Individual: $200  |  Family: $400
Preventive Care
$0
Office Visit
$5
Specialist Visit 
$20
Prescription Drugs
Tier 1: $1 Tier 2: 10% Tier 3: 40%
Urgent Care
$35
Emergency Room
10%
Inpatient Hospital
10%
Outpatient Surgery
10%
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract

Standard HMO Copayment 10

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In-Network Deductible
Individual: $0  |  Family: $0
Preventive Care
$0
Office Visit
$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