Plan Details
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
$3,000 Copay Plan
Tier 1: Missouri Health Cooperative
Tier 2: Healthlink/First Health
Out-of-Network
Deductible
Individual
Individual Under Family
Family
$0
$3,000
$6,000
$12,000
Out-of-Pocket Maximum
$24,000
Preventive Care Services
No Charge
50%*
Office Visits
Primary Office Visit
Specialist Office Visit
Chiropractic Visit
$35 Copay
$55 Copay
20%*
Urgent Care Services
$75 Copay
Complex Imaging: MRI/CT/PET Scans
Inpatient Hospital Care
Facility Fee
Physician Fee
Outpatient Procedures
Emergency Room
Medical Transportation
$500 Copay
Mental Health/Chemical Dependency
Inpatient
Office Visit
Prescription Drug Coverage
Generic
Preferred Brand
Non-Preferred Brand
Specialty Drugs
Retail 30 Day Supply
$200 Copay
Mail Order 90 Day Supply
$70 Copay
$150 Copay
Not Available
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 844-678-9688