10
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