Click on plan name link to view full benefit summary.
| Plan Name |
Deductible |
Description |
Summary of Benefit Design |
| HM-OA-5477 |
1250 |
First dollar coverage for office visits, Co-pay only plan after meeting the Deductible |
HM-OA-5477 - Open Access HMO 25/1250/1500; RX$20/$40/$60/$75 w/ OC |
| HM-OA-5478 |
2000 |
First dollar coverage for office visits, Co-pay only plan after meeting the Deductible |
HM-OA-5478 - Open Access HMO 25/2000/1500; RX$20/$40/$60/$75 w/ OC |
| HM-OA-5479 |
3000 |
First dollar coverage for office visits, Co-pay only plan after meeting the Deductible |
HM-OA-5479 - Open Access HMO 25/3000/1500; RX$20/$40/$60/$75 w/ OC |
| HM-OA-5480 |
3500 |
First dollar coverage for office visits, Co-pay only plan after meeting the Deductible |
HM-OA-5480 - Open Access HMO 25/3500/1500; RX$20/$40/$60/$75 w/ OC |
| HM-OA-5481 |
4000 |
First dollar coverage for office visits, Co-pay only plan after meeting the Deductible |
HM-OA-5481 - Open Access HMO 25/4000/1500; RX$20/$40/$60/$75 w/ OC |
| HM-OA-5482 |
4500 |
First dollar coverage for office visits, Co-pay only plan after meeting the Deductible |
HM-OA-5482 - Open Access HMO 25/4500/1500; RX$20/$40/$60/$75 w/ OC |
| HM-OA-5483 |
7500 |
First dollar coverage for office visits, Co-pay only plan after meeting the Deductible |
HM-OA-5483- Open Access HMO 25/7500/1500; RX$20/$40/$60/$75 w/ OC |
| CH-CH-5485 |
1000 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
Rx $15/30/50/75 OC |
| CH-CH-5484 |
2000 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
RX$20/$40/$60/$75 w/ OC |