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

Tier 1 - Missouri Health Cooperative

Tier 2 - Healthlink/FNS

Tier 3 - Out of Network

Deductible

Individual

Individual Under Family

Family

 

$0

$0

$0

 

$2,500

$2,500

$5,000

 

$10,000

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$0

$0

$0

 

$6,250

$6,250

$12,500

 

$20,000

$20,000

$40,000

Preventive Care Services

No charge

No charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

No Charge

No Charge

No Charge

 

$35 Copay

$45 Copay

20%*

 

50%*

50%*

50%*

Urgent Care Services

No Charge

$50 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

No Charge

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

No Charge

No Charge

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

No Charge

No Charge

 

20%*

20%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

No Charge

No Charge

0%*

0%*

50%*

50%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

No Charge

No Charge

 

20%*

$35 copay

 

50%*

50%*

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 866-478-6268