Premium$33MOOP $3,200PCP$0Specialist$25Referrals RequiredNoInpatient Hospital$175 (days 1-5)Ambulatory Surgery Center$0 or $110Outpatient Hospital$0 or $160Lab

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Premium$33MOOP $3,200PCP$0Specialist$25Referrals RequiredNoInpatient Hospital$175 (days 1-5)Ambulatory Surgery Center$0 or $110Outpatient Hospital$0 or $160Lab

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Premium$0MOOP $3,700PCP$0Specialist$30Referrals RequiredNoInpatient Hospital$250 (days 1-5)Ambulatory Surgery Center$0 or $175Outpatient Hospital$0 or $225Lab

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Premium$0MOOP $3,700PCP$0Specialist$30Referrals RequiredNoInpatient Hospital$250 (days 1-5)Ambulatory Surgery Center$0 or $175Outpatient Hospital$0 or $225Lab

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Premium$43MOOP $4,900PCP$0Specialist$25Referrals RequiredNoInpatient Hospital$295 (days 1-5)Ambulatory Surgery Center$0 or $225Outpatient Hospital$0 or $275Lab

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