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Individual Health Plans

  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

 

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