Plan Details

Not all coverage is the right coverage.

Your healthcare coverage is important to us. Age, family status, medical conditions, hobbies, lifestyle and a myriad of other factors will help you determine if you need a lot or a very little amount of health coverage. This summary will help you understand your plan and its coverage.

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Summary of Medical Benefits

Copay Plan

Missouri Health Co-Op

HealthLink

Out of Network

Deductible

Individual

Family

 

$0

$0

 

$3,000

$7,000

 

$6,000

$14,000

Out-of-Pocket Maximum

Individual

Family

 

$4,500

$9,000

 

$4,500

$9,000

 

$8,000

$16,000

Preventive Care Services

No Charge

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

No Charge

No Charge

 

$60 Copay

$75 Copay

20%*

 

40%*

40%*

40%*

Urgent Care Services

$40 Copay

$60 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

No Charge

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

No Charge

No Charge

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

No Charge

No Charge

 

20%*

20%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

$250 Copay (waived if admitted)

20%*

$250 Copay (waived if admitted)

20%*

$250 Copay (waived if admitted)

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

No Charge

No Charge

 

20%*

$75 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$5 Copay

$15 Copay

$25 Copay

$100 Copay

Mail Order 90 Day Supply

$10 Copay

$30 Copay

$50 Copay

Not Covered

 

 

 

 

 

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

 

 

If you prefer talking with a HealthEZ representative, call 855-290-1411