| HDHMO HSA-Qualified 33 |
|
In-Network Deductible
Individual: $2,750
Family: $5,500
|
|
Preventive Care**
$0
|
|
Office Visit
15%*
|
|
Doctor on Demand Visits
0%*
|
|
Specialist Visit
15%*
|
|
Prescription Drugs**
Tier 1: $4*
Tier 2: 50%*
Tier 3: 50%*
|
|
Urgent Care
15%*
|
|
Emergency Room
15%*
|
|
Inpatient Hospital
15%*
|
|
Outpatient Surgery
15%*
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|
| Standard HMO Copayment 30 |
|
In-Network Deductible
Individual: $1,300
Family: $2,600
|
|
Preventive Care**
$0
|
|
Office Visit
$30*
|
|
Doctor on Demand Visits
$30*
|
|
Specialist Visit
$50*
|
|
Prescription Drugs**
Tier 1: $10
Tier 2: $35
Tier 3: $70
|
|
Urgent Care
$70*
|
|
Emergency Room
$300*
|
|
Inpatient Hospital
$1,500*
|
|
Outpatient Surgery
$150*
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|
| HMO Smart Deductible EPC 34 |
|
In-Network Deductible
Individual: $5,000
Family: $10,000
|
|
Preventive Care**
$0
|
|
Office Visit
0% EPC | 15% non-EPC
|
|
Doctor on Demand Visits
0%*
|
|
Specialist Visit
15%*
|
|
Prescription Drugs**
Tier 1: $4
Tier 2: 30%*
Tier 3: 50%*
|
|
Urgent Care
15%*
|
|
Emergency Room
15%*
|
|
Inpatient Hospital
15%*
|
|
Outpatient Surgery
15%*
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|
| HDHMO HSA-Qualified 35 |
|
In-Network Deductible
Individual: $2,000
Family: $4,000
|
|
Preventive Care**
$0
|
|
Office Visit
$25*
|
|
Doctor on Demand Visits
$0*
|
|
Specialist Visit
$50*
|
|
Prescription Drugs**
Tier 1: $10*
Tier 2: $50*
Tier 3: $80*
|
|
Urgent Care
$75*
|
|
Emergency Room
$500*
|
|
Inpatient Hospital
$1,500*
|
|
Outpatient Surgery
$200*
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|
*Subject to deductible
**Preventive Care and Prescription Drugs Are Not Subject to Deductible
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