Page 5 - OMS Benefits Guide
P. 5
HAP Plan Summaries
Base HAP EPO Bronze $5,500 HDHP Buy-Up HAP HMO Silver $2,500
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Service Benefit Service Benefit
$5,500 Single / $2,500 Single /
Deductible Deductible
$11,0000 Family $5,000 Family
Coinsurance 20% Coinsurance 30%
Out of Pocket $6,650 Single / Out of Pocket $7,900 Single /
Maximum $13,300 Family
Maximum $15,800 Family
Covered After
Primary Care Visit Primary Care Visit
Deductible $40
Copay
Specialist Visit
Specialist Visit
Covered After $60
Emergency Room Copay
Deductible
Emergency Room $300 After
Covered After
Urgent Care Copay Deductible
Deductible
Urgent Care Copay $65
Please note: These are brief descriptions. Read plan certificates for limitation, exclusions,
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and plan specifics.
