HMO Core Plans
| Plan Name | Deductible | Coinsurance | Out of Pocket | Office Visit Copay | Prescription Benefits | ||||
| Single | Family | NHP | Member | Single | Family | PCP | Specialist | ||
| HMO 1 | N/A | N/A | N/A | N/A | N/A | N/A | $15 | $30 | Options |
| HMO 2 | $250 | $500 | 80% | 20% | $1,500 | $3,000 | $20 | $40 | Options |
| HMO 3 | $250 | $500 | 80% | 20% | $2,500 | $5,000 | $25 | $50 | Options |
| HMO 4 | $250 | $500 | 80% | 20% | $3,000 | $6,000 | $25 | $50 | Options |
| HMO 5 | $500 | $1,500 | 80% | 20% | $3,500 | $7,000 | $25 | $50 | Options |
| HMO 6 | $750 | $2,250 | 80% | 20% | $4,000 | $8,000 | $25 | $50 | Options |
| HMO 7 | $1,000 | $3,000 | 80% | 20% | $4,500 | $9,000 | $30 | $60 | Options |
| HMO 8 | $2,000 | $6,000 | 80% | 20% | $5,000 | $10,000 | $30 | $60 | Options |
| HMO $20 COPAY | N/A | N/A | N/A | N/A | $2,000 | $4,000 | $20 | $40 | Options |
| HMO $30 COPAY | N/A | N/A | N/A | N/A | $3,000 | $6,000 | $30 | $60 | Options |
| CDHMO 1 | $1,500 | $3,000 | 100% | 0% | $1,500 | $3,000 | D/C | D/C | Options |
| CDHMO 2 | $2,500 | $5,000 | 100% | 0% | $2,500 | $5,000 | D/C | D/C | Options |
| CDHMO 3 | $3,500 | $7,000 | 100% | 0% | $3,500 | $7,000 | D/C | D/C | Options |
| H250 COCHOICE | $250 | $500 | 80% | 20% | $2,250 | $4,500 | $30 | $60 | Options |
| H500 COCHOICE | $500 | $1,000 | 80% | 20% | $2,500 | $5,000 | $30 | $60 | Options |
| H750 COCHOICE | $750 | $1,500 | 80% | 20% | $2,750 | $5,500 | $30 | $60 | Options |
| H1000 COCHOICE | $1,000 | $2,000 | 80% | 20% | $3,000 | $6,000 | $30 | $60 | Options |
| H1000 EXCOCHOICE | $1,000 | $2,000 | 70% | 30% | $2,500 | $5,000 | $25 | $50 | Options |
| H1500 COCHOICE | $1,500 | $3,000 | 80% | 20% | $3,500 | $7,000 | $30 | $60 | Options |
| H2000 COCHOICE | $2,000 | $4,000 | 80% | 20% | $4,000 | $8,000 | $30 | $60 | Options |
| H2500 COCHOICE | $2,500 | $5,000 | 80% | 20% | $4,500 | $9,000 | $30 | $60 | Options |
| H3000 COCHOICE | $3,000 | $6,000 | 80% | 20% | $5,000 | $10,000 | $30 | $60 | Options |
| H3500 COCHOICE | $3,500 | $7,000 | 80% | 20% | $5,500 | $11,000 | $30 | $60 | Options |
| H4000 COCHOICE | $4,000 | $8,000 | 80% | 20% | $6,000 | $12,000 | $30 | $60 | Options |
| H4500 COCHOICE | $4,500 | $9,000 | 80% | 20% | $6,500 | $13,000 | $30 | $60 | Options |
| H5000 COCHOICE | $5,000 | $10,000 | 80% | 20% | $7,000 | $14,000 | $30 | $60 | Options |
| HSAH1500 - 0% | $1,500 | $3,000 | 100% | 0% | $1,500 | $3,000 | D | D | Options |
| HSAH1500 - 10% | $1,500 | $3,000 | 90% | 10% | $2,000 | $4,000 | D/C | D/C | Options |
| HSAH1500 - 20% | $1,500 | $3,000 | 80% | 20% | $2,500 | $5,000 | D/C | D/C | Options |
| HSAH2000 - 0% | $2,000 | $4,000 | 100% | 0% | $2,000 | $4,000 | D | D | Options |
| HSAH2000 - 10% | $2,000 | $4,000 | 90% | 10% | $2,500 | $5,000 | D/C | D/C | Options |
| HSAH2000 - 20% | $2,000 | $4,000 | 80% | 20% | $3,000 | $6,000 | D/C | D/C | Options |
| HSAH2500 - 0% | $2,500 | $5,000 | 100% | 0% | $2,500 | $5,000 | D | D | Options |
| HSAH2500 - 10% | $2,500 | $5,000 | 90% | 10% | $3,000 | $6,000 | D/C | D/C | Options |
| HSAH2500 - 20% | $2,500 | $5,000 | 80% | 20% | $3,500 | $7,000 | D/C | D/C | Options |
| HSAH3000 - 0% | $3,000 | $6,000 | 100% | 0% | $3,000 | $6,000 | D | D | Options |
| HSAH3000 - 10% | $3,000 | $6,000 | 90% | 10% | $3,500 | $7,000 | D/C | D/C | Options |
| HSAH3000 - 20% | $3,000 | $6,000 | 80% | 20% | $4,000 | $8,000 | D/C | D/C | Options |
| HSAH3500 - 0% | $3,500 | $7,000 | 100% | 0% | $3,500 | $7,000 | D | D | Options |
| HSAH3500 - 20% | $3,500 | $7,000 | 80% | 20% | $4,500 | $9,000 | D/C | D/C | Options |
| HSAH4000 - 0% | $4,000 | $8,000 | 100% | 0% | $4,000 | $8,000 | D | D | Options |
| HSAH4000 - 20% | $4,000 | $8,000 | 80% | 20% | $5,000 | $10,000 | D/C | D/C | Options |
| HSAH4500 - 0% | $4,500 | $9,000 | 100% | 0% | $4,500 | $9,000 | D | D | Options |
| HSAH4500 - 20% | $4,500 | $9,000 | 80% | 20% | $5,500 | $11,000 | D/C | D/C | Options |
| HSAH5000 - 0% | $5,000 | $10,000 | 100% | 0% | $5,000 | $10,000 | D | D | Options |
| HSAH5000 - 20% | $5,000 | $10,000 | 80% | 20% | $5,600 | $11,200 | D/C | D/C | Options |
D/C = Deductible and Coinsurance
Please note: These plans are effective Sept. 1, 2008. This summary is intended to highlight and give a general description of some of the benefits available. For a complete description of benefits, limitations and exclusions, please refer to the Member Responsibility Tables and Certificate of Coverage.
