Platinum Plans

HMO Hybrid 13
In-Network Deductible Individual: $200 Family: $400
Preventive Care $0
Office Visit $15
Doctor on Demand Visits $0
Specialist Visit $20
Prescription Drugs Tier 1: $1 Tier 2: 10% Tier 3: 40%
Urgent Care $40
Emergency Room 10%*
Inpatient Hospital 10%*
Outpatient Surgery 10%*
Plan Documents Summary of Benefits & Coverage Health Plan Contract

HMO Hybrid 13

In-Network Deductible

Individual: $200

Family: $400

Preventive Care

Office Visit

$15

Doctor on Demand Visits

Specialist Visit

$20

Prescription Drugs

Tier 1: $1

Tier 2: 10%

Tier 3: 40%

Urgent Care

$40

Emergency Room

10%*

Inpatient Hospital

10%*

Outpatient Surgery

10%*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

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

Standard HMO Copayment 10

In-Network Deductible

Individual: $0

Family: $0

Preventive Care

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

HMO Copayment 14
In-Network Deductible Individual: $0 Family: $0
Preventive Care $0
Office Visit $0
Doctor on Demand Visits $0
Specialist Visit $25
Prescription Drugs Tier 1: $5 Tier 2: $15 Tier 3: $45
Urgent Care $50
Emergency Room $200
Inpatient Hospital $250
Outpatient Surgery $100
Plan Documents Summary of Benefits & Coverage Health Plan Contract

HMO Copayment 14

In-Network Deductible

Individual: $0

Family: $0

Preventive Care

Office Visit

Doctor on Demand Visits

Specialist Visit

$25

Prescription Drugs

Tier 1: $5

Tier 2: $15

Tier 3: $45

Urgent Care

$50

Emergency Room

$200

Inpatient Hospital

$250

Outpatient Surgery

$100

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

*subject to deductible

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Platinum Plans

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