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HMO Plan Design

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A HMO PROVIDER

Benefit

Copay

Deductible

Annual Out-of-Pocket

Maximum

Office Visit Copay

Lab and X-Ray Copay

Hospital Inpatient Copay

LASIK

Body Scan

Chiropractic Copay

Prescription Drugs

$0 

$1,500 per individual,

$3,000 per family

$10

$10

$500

$1,500 lifetime benefit

per eye

Once every 24 months,

member and spouse only

$5

$10 for generics**

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*After deductible has been met

**Effective 1/1/17, now uses Essential Drug List