Your Medical Benefits
HMO - Full HMO
Benefit Summary
Group # 3346200
An HMO, or Health Maintenance Organization, is a health plan that offers a network of doctors and hospitals for you to choose from. You must choose a primary care provider (PCP) to coordinate your health care.
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Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | HMO - Full HMO | |
| Plan Coinsurance | Plan pays 100% | Not Covered for all benefits |
| Plan Deductible (Individual) | Individual: None | Not Covered for all benefits |
| Plan Deductible (Family) | Family: None | Not Covered for all benefits |
| Plan Out-of-Pocket (Individual) | Individual: $2,000 | Not Covered for all benefits |
| Plan Out-of-Pocket (Family) | Family: $4,000 | Not Covered for all benefits |
| Primary Care Physician Office Visit | $30 copay, and plan pays 100% | Not Covered for all benefits |
| Specialist Care Physician Office Visit | $50 copay, and plan pays 100% | Not Covered for all benefits |
| Emergency Room | $200 copay, and plan pays 100% | |
| Urgent Care | $30 copay, and plan pays 100% | Not Covered for all benefits |
| Outpatient Radiology | Plan pays 100% | Not Covered for all benefits |
| Independent Laboratory | Plan pays 100% | Not Covered for all benefits |
| Formulary Type | Standard | |
| Retail Pharmacy | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 | Not Covered for all benefits |
| Home Delivery Pharmacy | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 | Not Covered for all benefits |
| Outpatient Therapy and Chiropractic Services | Not Covered for all benefits | |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Benefit Summary
Group # 3346200
An HMO, or Health Maintenance Organization, is a health plan that offers a network of doctors and hospitals for you to choose from. You must choose a primary care provider (PCP) to coordinate your health care.
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | HMO - Full HMO | |
| Plan Coinsurance | Plan pays 100% | Not Covered for all benefits |
| Plan Deductible (Individual) | Individual: None | Not Covered for all benefits |
| Plan Deductible (Family) | Family: None | Not Covered for all benefits |
| Plan Out-of-Pocket (Individual) | Individual: $2,000 | Not Covered for all benefits |
| Plan Out-of-Pocket (Family) | Family: $4,000 | Not Covered for all benefits |
| Primary Care Physician Office Visit | $30 copay, and plan pays 100% | Not Covered for all benefits |
| Specialist Care Physician Office Visit | $50 copay, and plan pays 100% | Not Covered for all benefits |
| Emergency Room | $200 copay, and plan pays 100% | |
| Urgent Care | $30 copay, and plan pays 100% | Not Covered for all benefits |
| Outpatient Radiology | Plan pays 100% | Not Covered for all benefits |
| Independent Laboratory | Plan pays 100% | Not Covered for all benefits |
| Formulary Type | Standard | |
| Retail Pharmacy | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 | Not Covered for all benefits |
| Home Delivery Pharmacy | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 | Not Covered for all benefits |
| Outpatient Therapy and Chiropractic Services | Not Covered for all benefits | |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.