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← Back to All Plans EPO, HSA-Compatible – In-Network Only

1750 HSA EPO

The full-featured EPO design with an HSA-eligible deductible, so members can pair the plan with tax-advantaged HSA contributions.

Annual Deductible (Ind / Family)
$1,750 / $3,500
Out-of-Pocket Max (Ind / Family)
$8,500 / $17,000
Network
In-network only (except true emergencies)
BenefitWhat You Pay
Primary Care Visit$50 copay after deductible
Specialist Visit$75 copay after deductible
Urgent Care$100 copay after deductible
Telemedicine (MYMDNOW)$0 copay, unlimited visits
Emergency Room$1,000 copay after deductible
Inpatient Hospital Care$2,500 copay/admission after deductible
HSA ContributionPlan contributes $25/month; employer contribution amount is employer-determined

Prescription Drug Benefits

Drug TierWhat You Pay
Rx Preventive / Maintenance$0 copay
Retail Generic Rx$0 copay
Brand & Specialty DrugsNot covered (patient assistance programs may be available)
This is an in-network-only plan. Any provider may be used for a true emergency without penalty.

Want the Full Plan Details?

This page summarizes the key benefits only. For the complete Summary of Benefits, exclusions, and plan documentation, return to your plan overview page and schedule time with the benefits advisor affiliated with your association.

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