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2017 Plans
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Pediatric dental benefits are required by the ACA. Although our medical plans don’t include pediatric dental benefits, you may choose an HMSA dental plan to get covered.

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Plan		Deductible	Max out– of–pocket	Coinsurance	Doctor visit copayment	Specialist visit copayment	Premiums based on age: Enter Age
Platinum PPO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 Tier 3 - mostly other brand name drugs: $75 ⁴ Tier 4 - mostly preferred specialty drugs: $150 or 20% whichever is greater Tier 5 – mostly other brand name specialty drugs: $150 or 30% whichever is greater Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Chiropractic, acupuncture, and massage therapy benefit. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$0	$6,850	10% - 20% ⁵	$20	$20	$273.52 / month $430.74 / month $430.74 / month $430.74 / month $430.74 / month $432.47 / month $441.08 / month $451.42 / month $468.22 / month $482.00 / month $488.90 / month $499.23 / month $509.57 / month $516.03 / month $522.92 / month $526.37 / month $529.82 / month $533.26 / month $536.71 / month $543.60 / month $550.49 / month $560.83 / month $570.74 / month $584.52 / month $601.75 / month $622.00 / month $646.12 / month $673.25 / month $704.27 / month $734.85 / month $769.31 / month $803.34 / month $840.81 / month $878.72 / month $919.64 / month $960.56 / month $1,004.93 / month $1,049.72 / month $1,097.54 / month $1,121.23 / month $1,169.04 / month $1,210.39 / month $1,237.53 / month $1,271.56 / month $1,292.22 / month $1,292.22 / month
Platinum HMO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 Tier 3 - mostly other brand name drugs: $75 ⁴ Tier 4 - mostly preferred specialty drugs: $150 or 20% whichever is greater Tier 5 – mostly other brand name specialty drugs: $150 or 30% whichever is greater Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Chiropractic, acupuncture, and massage therapy benefit. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$0	$7,150	10%	$10	$20	$268.21 / month $422.38 / month $422.38 / month $422.38 / month $422.38 / month $424.07 / month $432.52 / month $442.66 / month $459.13 / month $472.65 / month $479.41 / month $489.54 / month $499.68 / month $506.02 / month $512.77 / month $516.15 / month $519.53 / month $522.91 / month $526.29 / month $533.05 / month $539.81 / month $549.94 / month $559.66 / month $573.18 / month $590.07 / month $609.92 / month $633.58 / month $660.19 / month $690.60 / month $720.59 / month $754.38 / month $787.75 / month $824.49 / month $861.66 / month $901.79 / month $941.92 / month $985.42 / month $1,029.35 / month $1,076.24 / month $1,099.47 / month $1,146.35 / month $1,186.90 / month $1,213.51 / month $1,246.88 / month $1,267.14 / month $1,267.14 / month
Gold PPO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 Tier 3 - mostly other brand name drugs: $75 ⁴ Tier 4 - mostly preferred specialty drugs: $150 or 20% whichever is greater Tier 5 – mostly other brand name specialty drugs: $150 or 30% whichever is greater Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$0	$7,150	30%	$30	$30	$234.44 / month $369.20 / month $369.20 / month $369.20 / month $369.20 / month $370.68 / month $378.06 / month $386.92 / month $401.32 / month $413.14 / month $419.04 / month $427.91 / month $436.77 / month $442.30 / month $448.21 / month $451.17 / month $454.12 / month $457.07 / month $460.03 / month $465.93 / month $471.84 / month $480.70 / month $489.19 / month $501.01 / month $515.78 / month $533.13 / month $553.80 / month $577.06 / month $603.65 / month $629.86 / month $659.40 / month $688.56 / month $720.68 / month $753.17 / month $788.25 / month $823.32 / month $861.35 / month $899.75 / month $940.73 / month $961.03 / month $1,002.02 / month $1,037.46 / month $1,060.72 / month $1,089.89 / month $1,107.60 / month $1,107.60 / month
Gold PPO 1000	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 ¹ Tier 3 - mostly other brand name drugs: $75 ^{1, 4} Tier 4 - mostly preferred specialty drugs: $150 or 20% whichever is greater ¹ Tier 5 – mostly other brand name specialty drugs: $150 or 30% whichever is greater ¹ Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$1,000	$7,150	20% ¹	$20	$20	$222.32 / month $350.11 / month $350.11 / month $350.11 / month $350.11 / month $351.51 / month $358.51 / month $366.92 / month $380.57 / month $391.77 / month $397.38 / month $405.78 / month $414.18 / month $419.43 / month $425.04 / month $427.84 / month $430.64 / month $433.44 / month $436.24 / month $441.84 / month $447.44 / month $455.85 / month $463.90 / month $475.10 / month $489.11 / month $505.56 / month $525.17 / month $547.22 / month $572.43 / month $597.29 / month $625.30 / month $652.96 / month $683.42 / month $714.23 / month $747.49 / month $780.75 / month $816.81 / month $853.22 / month $892.08 / month $911.34 / month $950.20 / month $983.81 / month $1,005.87 / month $1,033.53 / month $1,050.33 / month $1,050.33 / month
Gold HMO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 ¹ Tier 3 - mostly other brand name drugs: $75 ^{1, 4} Tier 4 - mostly preferred specialty drugs: $150 or 20% whichever is greater ¹ Tier 5 – mostly other brand name specialty drugs: $150 or 30% whichever is greater ¹ Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$1,000	$7,150	20% ¹	$15	$30	$216.83 / month $341.46 / month $341.46 / month $341.46 / month $341.46 / month $342.82 / month $349.65 / month $357.85 / month $371.17 / month $382.09 / month $387.56 / month $395.75 / month $403.95 / month $409.07 / month $414.53 / month $417.26 / month $419.99 / month $422.73 / month $425.46 / month $430.92 / month $436.38 / month $444.58 / month $452.43 / month $463.36 / month $477.02 / month $493.07 / month $512.19 / month $533.70 / month $558.28 / month $582.53 / month $609.84 / month $636.82 / month $666.53 / month $696.58 / month $729.01 / month $761.45 / month $796.62 / month $832.13 / month $870.04 / month $888.82 / month $926.72 / month $959.50 / month $981.01 / month $1,007.99 / month $1,024.38 / month $1,024.38 / month
Silver PPO 1500	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $10 Tier 2 - mostly preferred drugs: $50 ¹ Tier 3 - mostly other brand name drugs: $100 ^{1, 3} Tier 4 - mostly preferred specialty drugs: $200 or 20% whichever is greater ¹ Tier 5 – mostly other brand name specialty drugs: $200 or 30% whichever is greater ¹ Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$1,500	$7,150	30% - 50% ^1,5	$40	$40	$189.70 / month $298.75 / month $298.75 / month $298.75 / month $298.75 / month $299.94 / month $305.92 / month $313.09 / month $324.74 / month $334.30 / month $339.08 / month $346.25 / month $353.42 / month $357.90 / month $362.68 / month $365.07 / month $367.46 / month $369.85 / month $372.24 / month $377.02 / month $381.80 / month $388.97 / month $395.84 / month $405.40 / month $417.35 / month $431.39 / month $448.12 / month $466.94 / month $488.45 / month $509.66 / month $533.56 / month $557.16 / month $583.15 / month $609.44 / month $637.82 / month $666.21 / month $696.98 / month $728.05 / month $761.21 / month $777.64 / month $810.80 / month $839.48 / month $858.30 / month $881.90 / month $896.25 / month $896.25 / month
Silver PPO 2500	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $10 Tier 2 - mostly preferred drugs: $50 ¹ Tier 3 - mostly other brand name drugs: $100 ^{1, 3} Tier 4 - mostly preferred specialty drugs: $200 or 20% whichever is greater ¹ Tier 5 – mostly other brand name specialty drugs: $200 or 30% whichever is greater ¹ Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$2,500	$7,150	20% - 30% ^1,5	$30	$30	$183.45 / month $288.90 / month $288.90 / month $288.90 / month $288.90 / month $290.06 / month $295.84 / month $302.77 / month $314.04 / month $323.28 / month $327.91 / month $334.84 / month $341.77 / month $346.11 / month $350.73 / month $353.04 / month $355.35 / month $357.66 / month $359.97 / month $364.60 / month $369.22 / month $376.15 / month $382.80 / month $392.04 / month $403.60 / month $417.18 / month $433.36 / month $451.56 / month $472.36 / month $492.87 / month $515.98 / month $538.80 / month $563.94 / month $589.36 / month $616.81 / month $644.25 / month $674.01 / month $704.06 / month $736.13 / month $752.02 / month $784.08 / month $811.82 / month $830.02 / month $852.84 / month $866.70 / month $866.70 / month
Silver PPO 3500	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $15 Tier 2 - mostly preferred drugs: $50 Tier 3 - mostly other brand name drugs: $100 ³ Tier 4 - mostly preferred specialty drugs: 40% Tier 5 – mostly other brand name specialty drugs: 40% Additional benefits Urgent Care visit: $75 Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary Get hard copies of HMSA plan materials.	$3,500	$7,150	20% ¹	$30	$65	$178.51 / month $281.12 / month $281.12 / month $281.12 / month $281.12 / month $282.25 / month $287.87 / month $294.62 / month $305.58 / month $314.58 / month $319.07 / month $325.82 / month $332.57 / month $336.78 / month $341.28 / month $343.53 / month $345.78 / month $348.03 / month $350.28 / month $354.78 / month $359.27 / month $366.02 / month $372.49 / month $381.48 / month $392.73 / month $405.94 / month $421.68 / month $439.39 / month $459.64 / month $479.59 / month $502.08 / month $524.29 / month $548.75 / month $573.49 / month $600.20 / month $626.90 / month $655.86 / month $685.10 / month $716.30 / month $731.76 / month $762.97 / month $789.95 / month $807.66 / month $829.87 / month $843.36 / month $843.36 / month
Silver HMO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $10 Tier 2 - mostly preferred drugs: $50 ¹ Tier 3 - mostly other brand name drugs: $100 ^{1, 3} Tier 4 - mostly preferred specialty drugs: $200 or 20% whichever is greater ¹ Tier 5 – mostly other brand name specialty drugs: $200 or 30% whichever is greater ¹ Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$2,500	$7,150	30% ¹	$20	$40	$177.75 / month $279.92 / month $279.92 / month $279.92 / month $279.92 / month $281.04 / month $286.64 / month $293.36 / month $304.28 / month $313.23 / month $317.71 / month $324.43 / month $331.15 / month $335.35 / month $339.83 / month $342.06 / month $344.30 / month $346.54 / month $348.78 / month $353.26 / month $357.74 / month $364.46 / month $370.90 / month $379.85 / month $391.05 / month $404.21 / month $419.88 / month $437.52 / month $457.67 / month $477.55 / month $499.94 / month $522.05 / month $546.41 / month $571.04 / month $597.63 / month $624.23 / month $653.06 / month $682.17 / month $713.24 / month $728.64 / month $759.71 / month $786.58 / month $804.22 / month $826.33 / month $839.76 / month $839.76 / month
Bronze PPO 7150	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $25 Tier 2 - mostly preferred drugs: $0 ¹ Tier 3 - mostly other brand name drugs: $0 ¹ Tier 4 - mostly preferred specialty drugs: $0 ¹ Tier 5 – mostly other brand name specialty drugs: $0 ¹ Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$7,150	$7,150	0%	$50 ²	$0 ¹	$160.22 / month $252.31 / month $252.31 / month $252.31 / month $252.31 / month $253.32 / month $258.36 / month $264.42 / month $274.26 / month $282.33 / month $286.37 / month $292.43 / month $298.48 / month $302.27 / month $306.30 / month $308.32 / month $310.34 / month $312.36 / month $314.38 / month $318.41 / month $322.45 / month $328.51 / month $334.31 / month $342.38 / month $352.47 / month $364.33 / month $378.46 / month $394.36 / month $412.52 / month $430.44 / month $450.62 / month $470.55 / month $492.51 / month $514.71 / month $538.68 / month $562.65 / month $588.63 / month $614.87 / month $642.88 / month $656.76 / month $684.76 / month $708.99 / month $724.88 / month $744.81 / month $756.93 / month $756.93 / month
Bronze HMO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $25 Tier 2 - mostly preferred drugs: $50 ¹ Tier 3 - mostly other brand name drugs: $100 ³ Tier 4 - mostly preferred specialty drugs: $200 or 20% whichever is greater ¹ Tier 5 – mostly other brand name specialty drugs: $200 or 30% whichever is greater ¹ Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$6,000	$7,150	40% ¹	$40 ²	$60 ¹	$147.60 / month $232.45 / month $232.45 / month $232.45 / month $232.45 / month $233.38 / month $238.03 / month $243.60 / month $252.67 / month $260.11 / month $263.83 / month $269.41 / month $274.99 / month $278.47 / month $282.19 / month $284.05 / month $285.91 / month $287.77 / month $289.63 / month $293.35 / month $297.07 / month $302.65 / month $307.99 / month $315.43 / month $324.73 / month $335.65 / month $348.67 / month $363.32 / month $380.05 / month $396.56 / month $415.15 / month $433.51 / month $453.74 / month $474.19 / month $496.28 / month $518.36 / month $542.30 / month $566.47 / month $592.28 / month $605.06 / month $630.86 / month $653.18 / month $667.82 / month $686.18 / month $697.35 / month $697.35 / month
Catastrophic Plan	This is single coverage for individuals under 30 years of age OR who have a hardship exemption from healthcare.gov. Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $0 ¹ Tier 2 - mostly preferred drugs: $0 ¹ Tier 3 - mostly other brand name drugs: $0 ¹ Tier 4 - mostly preferred specialty drugs: $0 ¹ Tier 5 – mostly other brand name specialty drugs: $0 ¹ Additional benefits Plan resources Summary of Benefits Coverage Guide to Benefits Summary of Changes Drug Formulary Get hard copies of HMSA plan materials.	$7,150	$7,150	0%	$50 ²	$0 ¹	$129.36 / month $203.72 / month $203.72 / month $203.72 / month $203.72 / month $204.54 / month $208.61 / month $213.50 / month $221.44 / month $227.96 / month $231.22 / month $236.11 / month $241.00 / month $244.06 / month $247.32 / month $248.95 / month $250.58 / month $252.21 / month $253.84 / month $257.09 / month $260.35 / month $265.24 / month $269.93 / month $276.45 / month $284.60 / month $294.17 / month $305.58 / month $318.41 / month $333.08 / month $347.55 / month $363.84 / month $379.94 / month $397.66 / month $415.59 / month $434.94 / month $454.30 / month $475.28 / month $496.47 / month $519.08 / month $530.28 / month $552.90 / month $572.45 / month $585.29 / month $601.38 / month $611.16 / month $611.16 / month

¹ Member’s cost after the deductible is met.
² First three visits are covered before you reach the deductible.
³ $50 copayment plus $50 other brand name cost share.
⁴ $30 copayment plus $45 other brand cost share.
⁵ Coinsurance varies depending on the service received.

Health benefits

These benefits are included in all HMSA individual plans and others are available when you enroll:

HMSA’s Online Care.
An annual preventive exam with no copayment.
Generic drug coverage*.
Adult vision coverage.

*Generic drugs are covered before you meet the deductible, except for single-source generic drugs (drugs manufactured by a single pharmaceutical company) dispensed at a pharmacy.

Our medical plans no longer include children’s dental benefits, but you can choose an HMSA pediatric dental plan to get covered.

Plan		Deductible	Max out– of–pocket	Coinsurance	Doctor visit copayment	Specialist visit copayment	Premiums based on age: Enter Age
Platinum PPO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 Tier 3 - mostly other brand name drugs: $75 ⁴ Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Chiropractic, acupuncture, and massage therapy benefit. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$0	$6,000	10% - 20% ⁵	$20	$20	$216.81 / month $341.43 / month $341.43 / month $341.43 / month $341.43 / month $342.80 / month $349.63 / month $357.82 / month $371.14 / month $382.06 / month $387.52 / month $395.72 / month $403.91 / month $409.03 / month $414.50 / month $417.23 / month $419.96 / month $422.69 / month $425.42 / month $430.89 / month $436.35 / month $444.54 / month $452.40 / month $463.32 / month $476.98 / month $493.03 / month $512.15 / month $533.66 / month $558.24 / month $582.48 / month $609.80 / month $636.77 / month $666.47 / month $696.52 / month $728.96 / month $761.39 / month $796.56 / month $832.07 / month $869.97 / month $888.75 / month $926.65 / month $959.42 / month $980.93 / month $1,007.91 / month $1,024.29 / month $1,024.29 / month
Platinum HMO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 Tier 3 - mostly other brand name drugs: $75 ⁴ Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Chiropractic, acupuncture, and massage therapy benefit. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$0	$6,850	10%	$10	$20	$211.00 / month $332.29 / month $332.29 / month $332.29 / month $332.29 / month $333.62 / month $340.26 / month $348.24 / month $361.20 / month $371.83 / month $377.15 / month $385.12 / month $393.10 / month $398.08 / month $403.40 / month $406.06 / month $408.72 / month $411.37 / month $414.03 / month $419.35 / month $424.67 / month $432.64 / month $440.28 / month $450.92 / month $464.21 / month $479.83 / month $498.43 / month $519.37 / month $543.29 / month $566.88 / month $593.47 / month $619.72 / month $648.63 / month $677.87 / month $709.44 / month $741.00 / month $775.23 / month $809.79 / month $846.67 / month $864.95 / month $901.83 / month $933.73 / month $954.67 / month $980.92 / month $996.87 / month $996.87 / month
Gold PPO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 Tier 3 - mostly other brand name drugs: $75 ⁴ Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$0	$6,850	30%	$30	$30	$183.26 / month $288.59 / month $288.59 / month $288.59 / month $288.59 / month $289.75 / month $295.52 / month $302.45 / month $313.70 / month $322.94 / month $327.55 / month $334.48 / month $341.41 / month $345.73 / month $350.35 / month $352.66 / month $354.97 / month $357.28 / month $359.59 / month $364.20 / month $368.82 / month $375.75 / month $382.39 / month $391.62 / month $403.16 / month $416.73 / month $432.89 / month $451.07 / month $471.85 / month $492.34 / month $515.43 / month $538.23 / month $563.33 / month $588.73 / month $616.15 / month $643.56 / month $673.29 / month $703.30 / month $735.33 / month $751.21 / month $783.24 / month $810.95 / month $829.13 / month $851.93 / month $865.77 / month $865.77 / month
Gold PPO 1000	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 ¹ Tier 3 - mostly other brand name drugs: $75 ^{1, 4} Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$1,000	$6,850	20% ¹	$20	$20	$168.69 / month $265.65 / month $265.65 / month $265.65 / month $265.65 / month $266.71 / month $272.03 / month $278.40 / month $288.76 / month $297.26 / month $301.51 / month $307.89 / month $314.26 / month $318.25 / month $322.50 / month $324.62 / month $326.75 / month $328.87 / month $331.00 / month $335.25 / month $339.50 / month $345.88 / month $351.99 / month $360.49 / month $371.11 / month $383.60 / month $398.47 / month $415.21 / month $434.34 / month $453.20 / month $474.45 / month $495.44 / month $518.55 / month $541.93 / month $567.16 / month $592.40 / month $619.76 / month $647.39 / month $676.87 / month $691.49 / month $720.97 / month $746.48 / month $763.21 / month $784.20 / month $796.95 / month $796.95 / month
Gold HMO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $7 Tier 2 - mostly preferred drugs: $30 Tier 3 - mostly other brand name drugs: $75 ^{1, 4} Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$1,000	$6,850	20% ¹	$15	$30	$164.79 / month $259.51 / month $259.51 / month $259.51 / month $259.51 / month $260.55 / month $265.74 / month $271.97 / month $282.09 / month $290.39 / month $294.55 / month $300.77 / month $307.00 / month $310.90 / month $315.05 / month $317.12 / month $319.20 / month $321.28 / month $323.35 / month $327.50 / month $331.66 / month $337.88 / month $343.85 / month $352.16 / month $362.54 / month $374.74 / month $389.27 / month $405.62 / month $424.30 / month $442.73 / month $463.49 / month $483.99 / month $506.57 / month $529.40 / month $554.06 / month $578.71 / month $605.44 / month $632.43 / month $661.24 / month $675.51 / month $704.32 / month $729.23 / month $745.58 / month $766.08 / month $778.53 / month $778.53 / month
Silver PPO 1500	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $10 Tier 2 - mostly preferred drugs: $50 ¹ Tier 3 - mostly other brand name drugs: $100 ^{1, 3} Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$1,500	$6,850	30% - 50% ⁵	$40	$40	$138.99 / month $218.88 / month $218.88 / month $218.88 / month $218.88 / month $219.75 / month $224.13 / month $229.38 / month $237.92 / month $244.92 / month $248.43 / month $253.68 / month $258.93 / month $262.22 / month $265.72 / month $267.47 / month $269.22 / month $270.97 / month $272.72 / month $276.22 / month $279.73 / month $284.98 / month $290.01 / month $297.02 / month $305.77 / month $316.06 / month $328.32 / month $342.11 / month $357.87 / month $373.41 / month $390.92 / month $408.21 / month $427.25 / month $446.51 / month $467.30 / month $488.10 / month $510.64 / month $533.41 / month $557.70 / month $569.74 / month $594.03 / month $615.05 / month $628.84 / month $646.13 / month $656.64 / month $656.64 / month
Silver PPO 2500	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $10 Tier 2 - mostly preferred drugs: $50 ¹ Tier 3 - mostly other brand name drugs: $100 ^{1, 3} Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$2,500	$6,850	20%	$30	$30	$136.81 / month $215.45 / month $215.45 / month $215.45 / month $215.45 / month $216.31 / month $220.62 / month $225.79 / month $234.19 / month $241.08 / month $244.53 / month $249.70 / month $254.87 / month $258.10 / month $261.55 / month $263.27 / month $265.00 / month $266.72 / month $268.45 / month $271.89 / month $275.34 / month $280.51 / month $285.47 / month $292.36 / month $300.98 / month $311.10 / month $323.17 / month $336.74 / month $352.25 / month $367.55 / month $384.79 / month $401.81 / month $420.55 / month $439.51 / month $459.98 / month $480.44 / month $502.63 / month $525.04 / month $548.96 / month $560.81 / month $584.72 / month $605.40 / month $618.98 / month $636.00 / month $646.35 / month $646.35 / month
Silver HMO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $10 Tier 2 - mostly preferred drugs: $50 ¹ Tier 3 - mostly other brand name drugs: $100 ^{1, 3} Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$2,500	$6,850	30%	$20	$40	$129.34 / month $203.69 / month $203.69 / month $203.69 / month $203.69 / month $204.50 / month $208.58 / month $213.47 / month $221.41 / month $227.93 / month $231.19 / month $236.08 / month $240.96 / month $244.02 / month $247.28 / month $248.91 / month $250.54 / month $252.17 / month $253.80 / month $257.06 / month $260.31 / month $265.20 / month $269.89 / month $276.41 / month $284.55 / month $294.13 / month $305.53 / month $318.37 / month $333.03 / month $347.49 / month $363.79 / month $379.88 / month $397.60 / month $415.53 / month $434.88 / month $454.23 / month $475.21 / month $496.39 / month $519.00 / month $530.20 / month $552.81 / month $572.37 / month $585.20 / month $601.29 / month $611.07 / month $611.07 / month
Bronze PPO 6850	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $10 Tier 2 - mostly preferred drugs: $0 ¹ Tier 3 - mostly other brand name drugs: $0 ¹ Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$6,850	$6,850	0%	$0 ¹	$0 ¹	$106.22 / month $167.28 / month $167.28 / month $167.28 / month $167.28 / month $167.95 / month $171.30 / month $175.31 / month $181.84 / month $187.19 / month $189.87 / month $193.88 / month $197.90 / month $200.40 / month $203.08 / month $204.42 / month $205.76 / month $207.10 / month $208.43 / month $211.11 / month $213.79 / month $217.80 / month $221.65 / month $227.00 / month $233.69 / month $241.56 / month $250.92 / month $261.46 / month $273.51 / month $285.38 / month $298.77 / month $311.98 / month $326.54 / month $341.26 / month $357.15 / month $373.04 / month $390.27 / month $407.67 / month $426.24 / month $435.44 / month $454.01 / month $470.06 / month $480.60 / month $493.82 / month $501.84 / month $501.84 / month
Bronze HMO	Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $10 Tier 2 - mostly preferred drugs: $50 ¹ Tier 3 - mostly other brand name drugs: $100 ^{1, 3} Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Fitness membership (With $75 annual copayment) Must be at least 16 years of age to participate. Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$5,000	$6,850	40% ¹	$30	$60	$98.61 / month $155.28 / month $155.28 / month $155.28 / month $155.28 / month $155.91 / month $159.01 / month $162.74 / month $168.79 / month $173.76 / month $176.25 / month $179.97 / month $183.70 / month $186.03 / month $188.52 / month $189.76 / month $191.00 / month $192.24 / month $193.48 / month $195.97 / month $198.45 / month $202.18 / month $205.75 / month $210.72 / month $216.93 / month $224.23 / month $232.93 / month $242.71 / month $253.89 / month $264.92 / month $277.34 / month $289.61 / month $303.12 / month $316.78 / month $331.53 / month $346.28 / month $362.28 / month $378.43 / month $395.67 / month $404.21 / month $421.44 / month $436.35 / month $446.13 / month $458.40 / month $465.84 / month $465.84 / month
Catastrophic Plan	This is single coverage for individuals under 30 years of age OR who have a hardship exemption from healthcare.gov. Plan Benefits (amount you pay) Prescription drugs (30-day supply) Tier 1 - mostly generic drugs: $0 ¹ Tier 2 - mostly preferred drugs: $0 ¹ Tier 3 - mostly other brand name drugs: $0 ¹ Tier 4 - mostly preferred specialty drugs: $0 Tier 5 – mostly other brand name specialty drugs: $0 Additional benefits Plan resources Summary of Benefits Coverage Guide to Benefits Drug Formulary	$6,850	$6,850	0%	$50 ²	$50 ²	$97.75 / month $153.93 / month $153.93 / month $153.93 / month $153.93 / month $154.55 / month $157.63 / month $161.32 / month $167.33 / month $172.25 / month $174.72 / month $178.41 / month $182.11 / month $184.41 / month $186.88 / month $188.11 / month $189.34 / month $190.57 / month $191.80 / month $194.27 / month $196.73 / month $200.42 / month $203.96 / month $208.89 / month $215.05 / month $222.28 / month $230.90 / month $240.60 / month $251.68 / month $262.61 / month $274.93 / month $287.09 / month $300.48 / month $314.03 / month $328.65 / month $343.27 / month $359.13 / month $375.14 / month $392.23 / month $400.69 / month $417.78 / month $432.56 / month $442.26 / month $454.42 / month $461.79 / month $461.79 / month

Health benefits

These benefits are included in all HMSA individual plans and others are available when you enroll:

HMSA’s Online Care.
An annual preventive exam with no copayment.
Generic drug coverage*.
Adult vision coverage.

*Generic drugs are covered before you meet the deductible, except for single-source generic drugs (drugs manufactured by a single pharmaceutical company) dispensed at a pharmacy.

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