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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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