$4,500 Indiv / $9,000 Family. $6,450 Indiv / $12,900 Family. After deductible is met, you pay: 20% Generic: 20% Brand: 40% Specialty: 50%
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1 Core Bronze HSA AIAN $4,500 Indiv / $9,000 Family Coinsurance up to a 90-day supply, except specialty $6,450 Indiv / $12,900 Family Generic: Generic: 15% Urgent care Hospitalization Emergency services Laboratory and radiology services Ambulatory outpatient services 15-IF _18
2 Core Silver HSA AIAN $2,800 Indiv / $5,600 Family Coinsurance up to a 90-day supply, except specialty $5,500 Indiv / $11,000 Family Generic: Brand: Generic: 5% Brand: 25% Urgent care Hospitalization Emergency services Laboratory and radiology services Ambulatory outpatient services 15-IF _19
3 Flex Bronze AIAN $6,000 Indiv / $12,000 Family Coinsurance up to a 90-day supply, except specialty $6,850 Indiv / $13,700 Family Primary: $40 First 3 visits =, then Specialty: Generic: $25 Generic: $20 Urgent care Primary: $40 or Hospitalization Emergency services Laboratory and radiology services Ambulatory outpatient services 15-IF _20
4 Flex Silver AIAN services received through Indian Health Services (IHS), an Indian Tribe, Tribal Organization, $1,500 Indiv / $3,000 Family Coinsurance up to a 90-day supply, except specialty $6,350 Indiv / $12,700 Family First 4 primary or specialty visits = Primary: $20 Specialty: $45 Generic: $10 Generic: $5 Urgent care Primary: $20 Hospitalization Emergency services $200 + Laboratory and radiology services Specialty: $45 Ambulatory outpatient services 15-IF _21
5 Flex Gold AIAN services received through Indian Health Services (IHS), an Indian Tribe, Tribal Organization, $600 Indiv / $1,200 Family Coinsurance up to a 90-day supply, except specialty $4,500 Indiv / $9,000 Family First 4 primary or specialty visits = Primary: $10 Specialty: $30 Generic: $10 Brand: $35 Generic: $5 Brand: $30 Urgent care Primary: $10 Hospitalization Emergency services $200 + Laboratory and radiology services Specialty: $30 Ambulatory outpatient services 15-IF _22
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