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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

First Health HSA

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,300

$6,600

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$3,300

$6,600

 

$5,000

$10,000

Preventive Care Services

No Charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

30%*

30%*

30%*

Urgent Care Services

0%*

30%*

Complex Imaging: MRI/CT/PET Scans

0%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Emergency Room

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

30%*

30%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

MO Health Cooperative Copay

Tier 1

Tier 2

Out-of-Network

Deductible

Individual

Family

 

$0

$0

 

$3,000

$6,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$7,000

$14,000

 

$7,000

$14,000

 

$10,000

$20,000

Preventive Care Services

No Charge

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

No Charge

No Charge

No Charge

 

$30 Copay

$30 Copay

$30 Copay

 

50%*

50%*

50%*

Urgent Care Services

No Charge

$50 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

No Charge

30%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

No Charge

No Charge

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

No Charge

No Charge

 

30%*

30%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

No Charge

No Charge

30%*

30%*

50%*

50%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

No Charge

No Charge

 

30%*

$30 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$45 Copay

$75 Copay

25% Coinsurance

Mail Order 90 Day Supply

$20 Copay

$90 Copay

$150 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 844-682-4031