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  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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