HMO Full Pay $0 Ded 10255050 Rx HMO Co-90 $0 Ded 10255050 Rx HMO Co-80 $500 Ded 10255050 Rx HMO Co-80 $1250 Ded 20406050 Rx HMO Co-80 $2500 Ded 20406050 Rx HMO Co-100 $2000 Ded HMO Co-70 $5000 Ded 20406050 Rx