Page 1 - HMO

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Plan 1H
Plan 2H
Plan 2Hb
Plan 3H
Benefit Period
Calendar year
Calendar year
Calendar year
Calendar year
Annual deductibles
None
$200 Individual
$400 Family
$200 Individual
$400 Family
$500 Individual
$1,000 Family
Member coinsurance
None
None
None
None
Coinsurance maximums*
NA
NA
NA
NA
Out of pocket maximum**
NA
NA
NA
NA
Preventive
Office visits related to periodic
physical exams and well baby exams
Covered
Covered
Covered
Covered
Immunizations, related lab tests & x-rays,
pap smears & mammograms
Covered
Covered
Covered
Covered
Outpatient Services
Office visit (PCP/Specialist)
$10/$20 copay
$15/$30 copay
$20/$40 copay
$30/$50 copay
$10/$20 copay after deductible
$15/$30 copay after deductible
$20/$40 copay after deductible
$30/$50 copay after deductible
$10/$20 copay
$15/$30 copay
$20/$40 copay
$30/$50 copay
$10/$20 copay after deductible
$15/$30 copay after deductible
$20/$40 copay after deductible
$30/$50 copay after deductible
Outpatient surgery and related services
$0 copay
$100 copay
$0 copay after deductible
$100 copay after deductible
$0 copay after deductible
$100 copay after deductible
$0 copay after deductible
$100 copay after deductible
Inpatient Services
Inpatient, labor/delivery, mental health,
chemical dependency
$0 copay
$500 copay
$1,000 copay
$0 copay after deductible
$500 copay after deductible
$1,000 copay after deductible
$0 copay after deductible
$500 copay after deductible
$1,000 copay after deductible
$0 copay after deductible
$500 copay after deductible
$1,000 copay after deductible
Emergency Services
Emergency care
$50 copay
$100 copay
$150 copay
$200 copay
$50 copay after deductible
$100 copay after deductible
$150 copay after deductible
$200 copay after deductible
$50 copay
$100 copay
$150 copay
$200 copay
$50 copay after deductible
$100 copay after deductible
$150 copay after deductible
$200 copay after deductible
Urgent care
$25 copay
$40 copay
$50 copay
$25 copay after deductible
$40 copay after deductible
$50 copay after deductible
$25 copay
$40 copay
$50 copay
$25 copay after deductible
$40 copay after deductible
$50 copay after deductible
Additional Benefits
Hearing Aids/Eyeglasses/Contact Lens
Optional
Optional
Optional
Optional
Prescription Drugs
Rx copay options
Generic/Preferred Brand/Non
Preferred Brand
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
Plan 3Hb
Plan 4H
Plan 4Hb
Plan 5H QHDHP
Plan 6H QHDHP
Calendar year
Calendar year
Calendar year
Calendar year
Calendar year
$500 Individual
$1,000 Family
$1,000 Individual
$2,000 Family
$1,000 Individual
$2,000 Family
$1,500 Individual
$3,000 Family
$2,500 Individual
$5,000 Family
None
None
None
20%
30%
NA
NA
NA
NA
NA
NA
NA
NA
$5,000 Individual
$10,000 Family
$5,000 Individual
$10,000 Family
Preventive
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Outpatient Services
$10/$20 copay
$15/$30 copay
$20/$40 copay
$30/$50 copay
$10/$20 copay after deductible
$15/$30 copay after deductible
$20/$40 copay after deductible
$30/$50 copay after deductible
$10/$20 copay
$15/$30 copay
$20/$40 copay
$30/$50 copay
20% after deductible
30% after deductible
$0 copay after deductible
$100 copay after deductible
$0 copay after deductible
$100 copay after deductible
$0 copay after deductible
$100 copay after deductible
20% after deductible
30% after deductible
Inpatient Services
$0 copay after deductible
$500 copay after deductible
$1,000 copay after deductible
$0 copay after deductible
$500 copay after deductible
$1,000 copay after deductible
$0 copay after deductible
$500 copay after deductible
$1,000 copay after deductible
20% after deductible
30% after deductible
Emergency Services
$50 copay
$100 copay
$150 copay
$200 copay
$50 copay after deductible
$100 copay after deductible
$150 copay after deductible
$200 copay after deductible
$50 copay
$100 copay
$150 copay
$200 copay
20% after deductible
30% after deductible
$25 copay
$40 copay
$50 copay
$25 copay after deductible
$40 copay after deductible
$50 copay after deductible
$25 copay
$40 copay
$50 copay
20% after deductible
30% after deductible
Additional Benefits
Optional
Optional
Optional
Not Covered
Not Covered
Prescription Drugs
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
$5/$30/$60 after deductible $5/$30/$60 after deductible
* Coinsurance on certain services
does not accumulate toward the
coinsurance maximums. Please
refer to individual benefit
summaries for details
** Out of Pocket Max includes
deductible and copays
NOTE:
The above comparisons are
to be used for general reference
only. Please refer to individual
benefit summaries for specific
benefit levels for each service.
HMO Plan Designs