|
|
HDHMO HSA-Qualified 33 |
|
Standard HMO Copayment 30 |
|
HMO Smart Deductible EPC 34 |
|
HDHMO HSA-Qualified 35 |
In-Network Deductible |
|
Individual: $2,750
Family: $5,500 |
|
Individual: $1,300
Family: $2,600 |
|
Individual: $5,000
Family: $10,000 |
|
Individual: $2,000
Family: $4,000 |
Preventive Care** |
|
$0 |
|
$0 |
|
$0 |
|
$0 |
Office Visit |
|
15%* |
|
$30* |
|
0% EPC | 15% non-EPC |
|
$25* |
Doctor on Demand Visits |
|
0%* |
|
$30* |
|
0%* |
|
$0* |
Specialist Visit |
|
15%* |
|
$50* |
|
15%* |
|
$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* |
|
15%* |
|
$75* |
Emergency Room |
|
15%* |
|
$300* |
|
15%* |
|
$500* |
Inpatient Hospital |
|
15%* |
|
$1,500* |
|
15%* |
|
$1,500* |
Outpatient Surgery |
|
15%* |
|
$150* |
|
15%* |
|
$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 |
*Subject to Deductible
**Preventive Care and Preventive Drugs Are Not Subject to Deductible
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