| HMO Hybrid 13 |
|
In-Network Deductible
Individual: $200
Family: $400
|
|
Preventive Care
$0
|
|
Office Visit
$15
|
|
Doctor on Demand Visits
$0
|
|
Specialist Visit
$20
|
|
Prescriptions Filled at Preferred Pharmacies1
Tier 1: $1
Tier 2: 10%
Tier 3: 40%
|
|
Prescriptions Filled at Non-Preferred Pharmacies
Tier 1: 50%
Tier 2: 50%
Tier 3: 50%
|
|
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
|
|
Prescriptions Filled at Preferred Pharmacies1
Tier 1: $10
Tier 2: $30
Tier 3: $60
|
|
Prescriptions Filled at Non-Preferred Pharmacies
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
|
|
Prescriptions Filled at Preferred Pharmacies1
Tier 1: $5
Tier 2: $15
Tier 3: $45
|
|
Prescriptions Filled at Non-Preferred Pharmacies
Tier 1: 50%
Tier 2: 50%
Tier 3: 50%
|
|
Urgent Care
$50
|
|
Emergency Room
$200
|
|
Inpatient Hospital
$250
|
|
Outpatient Surgery
$100
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|
Get a Quote
1The CDPHP® Preferred Rx Network includes pharmacies who have teamed up with us to keep costs low and quality high for CDPHP members. Learn more.
*Subject to deductible