What You Pay in the National HMO Plan

In-Network Out-of-Network
Deductible* $0 Individual
$0 Family
N/A
Out-of-Pocket Maximum $3,000 Individual
$6,000 Family
N/A
Preventive Care Covered at 100% You pay the full cost
Telehealth $25 copay (does not count toward deductible) $25 copay (does not count toward deductible)
Primary Care Office Visit $25 copay You pay the full cost
Specialist Office Visit $40 copay
Urgent Care $60 copay
Emergency Room $250 copay (waived if admitted) $250 copay (waived if admitted)
Hospitalization $300 copay You pay the full cost
Surgery $300 copay You pay the full cost
Lab, X-Ray, Imaging 100% covered (office visit copay may apply) You pay the full cost
Mental Health See the Mental Health section for more information.
Prescription Drugs** – You don’t have to meet your deductible before you receive a benefit for prescription drugs, as long as you use a network pharmacy.
Pharmacy-Filled Generic $12 copay You pay the full cost
Pharmacy-Filled Formulary You pay 30%
($40 min. / $80 max.)
Pharmacy-Filled Non-formulary You pay 50%
($80 min. / $160 max.)
Mail Ordered Generic $30 copay You pay the full cost
Mail Ordered Formulary You pay 30%
($80 min. / $160 max.)
Mail Ordered Non-formulary You pay 50%
($180 min. / $350 max.)