MEDICAL PLAN
SUMMARY OF COVERAGE
PLAN NAME
HMO HMO
Plan Type
In Network Coverage Deductible Out-of-Pocket Max Primary Care Visit Specialist Visit Outpatient Procedure Coinsurance
$0 / $0
Plan pays 100% $1,500 / $3,000
$15 Copay $15 Copay
$100 per procedure
Inpatient Visit
$250 per admit $100 per visit $15 per visit $10 / $20 / $20
Emergency Room
Urgent Care
Pharmacy (Retail - 30 day) Out of Network Coverage Deductibles
Coinsurance Out-of-Pocket Max
N/A
8
MEDICAL PLAN I
SENDOSO BENEFITS GUIDE
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