| HDHMO HSA-Qualified 44 |
|
In-Network Deductible
Individual: $6,250
Family: $12,500
|
|
Preventive Care2
$0
|
|
Office Visit
30%*
|
|
Doctor on Demand Visits
0%*
|
|
Specialist Visit
30%*
|
|
Prescriptions Filled at Preferred Pharmacies1
Tier 1: 50%*
Tier 2: 50%*
Tier 3: 50%*
|
|
Prescriptions Filled at Non-Preferred Pharmacies2
Tier 1: 50%*
Tier 2: 50%*
Tier 3: 50%*
|
|
Urgent Care
30%*
|
|
Emergency Room
30%*
|
|
Inpatient Hospital
30%*
|
|
Outpatient Surgery
30%*
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|
| Standard HDHMO HSA-Qualified 40 |
|
In-Network Deductible
Individual: $5,500
Family: $11,100
|
|
Preventive Care2
$0
|
|
Office Visit
50%*
|
|
Doctor on Demand Visits
50%*
|
|
Specialist Visit
50%*
|
|
Prescriptions Filled at Preferred Pharmacies1
Tier 1: $10*
Tier 2: $35*
Tier 3: $70*
|
|
Prescriptions Filled at Non-Preferred Pharmacies2
Tier 1: $10*
Tier 2: $35*
Tier 3: $70*
|
|
Urgent Care
50%*
|
|
Emergency Room
50%*
|
|
Inpatient Hospital
50%*
|
|
Outpatient Surgery
50%*
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|
| HDHMO HSA-Qualified 45 |
|
In-Network Deductible
Individual: $7,050
Family: $14,100
|
|
Preventive Care2
$0
|
|
Office Visit
0%*
|
|
Doctor on Demand Visits
0%*
|
|
Specialist Visit
0%*
|
|
Prescriptions Filled at Preferred Pharmacies1
Tier 1: 0%*
Tier 2: 0%
Tier 3: 0%
|
|
Prescriptions Filled at Non-Preferred Pharmacies**
Tier 1: 0%*
Tier 2: 0%*
Tier 3: 0%*
|
|
Urgent Care
0%*
|
|
Emergency Room
0%*
|
|
Inpatient Hospital
0%*
|
|
Outpatient Surgery
0%*
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|
| Standard HDHMO Non HSA-Qualified 60 |
|
In-Network Deductible
Individual: $3,800
Family: $7,600
|
|
Preventive Care2
$0
|
|
Office Visit
$50 Copayment*
First 3 visits to a PCP/Specialist are not subject to the deductible
|
|
Doctor on Demand Visits
$50*
|
|
Specialist Visit
$75 Copayment*
First 3 visits to a PCP/Specialist are not subject to the deductible
|
|
Prescriptions Filled at Preferred Pharmacies1
Tier 1: $10*
Tier 2: $35*
Tier 3: $70*
|
|
Prescriptions Filled at Non-Preferred Pharmacies2
Tier 1: $10*
Tier 2: $35*
Tier 3: $70*
|
|
Urgent Care
$75*
|
|
Emergency Room
$500*
|
|
Inpatient Hospital
$1,500*
|
|
Outpatient Surgery
$150*
|
|
Plan Documents
Summary of Benefits & Coverage
Health Plan Contract
|
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1The CDPHP® Preferred Rx Network includes pharmacies who have teamed up with us to keep costs low and quality high for CDPHP members. Learn more.
2Preventive Care and Prescription Drugs Are Not Subject to Deductible
*Subject to deductible