	HDHMO HSA-Qualified 33	Standard HMO Copayment 30	HMO Smart Deductible EPC 34	HDHMO HSA-Qualified 35
In-Network Deductible	Individual: $2,500 Family: $5,000	Individual: $1,300 Family: $2,600	Individual: $4,000 Family: $8,000	Individual: $1,600 Family: $3,200
Preventive Care	$0	$0	$0	$0
Office Visit	15%	$30	0% EPC \| 10% non-EPC	$25
Live Video Doctor Visits	15%	$30	10%	$25
Specialist Visit	15%	$50	10%	$50
Prescription Drugs	Tier 1: $4 Tier 2: 50% Tier 3: 50%	Tier 1: $10 Tier 2: $35 Tier 3: $70	Tier 1: $4 Tier 2: 30% Tier 3: 50%	Tier 1: $10 Tier 2: $50 Tier 3: $80
Urgent Care	15%	$70	10%	$60
Emergency Room	15%	$250	10%	$500
Inpatient Hospital	15%	$1,500	10%	$1,500
Outpatient Surgery	15%	$150	10%	$200
Plan Documents	Summary of Benefits & Coverage Health Plan Contract	Summary of Benefits & Coverage Health Plan Contract	Summary of Benefits & Coverage Health Plan Contract	Summary of Benefits & Coverage Health Plan Contract

Individual Health Plans