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

PPO Plan

Tier 1 In-Network

Tier 2 In-Network

Out of Network

Deductible

Individual

Family

 

$1,500

$3,000

 

$3,000

$6,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$3,000

$6,000

 

$6,000

$12,000

 

$20,000

$60,000

Preventive Care Services

No Charge

No Charge

30%*

Office Visits

Primary Office Visit


Specialist Office Visit


Chiropractic Visit

 

John J Pershing: No Charge

MO Health COOP: 10%*

John J Pershing: No Charge

MO Health COOP: 10%*

John J Pershing: No Charge

MO Health COOP: 10%*

 

20%*

 

20%*

 

20%*

 

 

30%*

 

30%*

 

30%*

 

Urgent Care Services

John J Pershing: No Charge

MO Health COOP: 10%*

20%*

 

30%*

 

Complex Imaging: MRI/CT/PET Scans

John J Pershing: No Charge

MO Health COOP: 10%*

20%*

 

30%*

 

Inpatient Hospital Care

Facility Fee


Physician Fee

 

John J Pershing: No Charge

MO Health COOP: 10%*

John J Pershing: No Charge

MO Health COOP: 10%*

 

20%*

 

20%*

 

 

30%*

 

30%*

 

Outpatient Procedures

Facility Fee


Physician Fee

 

John J Pershing: No Charge

MO Health COOP: 10%*

John J Pershing: No Charge

MO Health COOP: 10%*

 

20%*

 

20%*

 

 

30%*

 

30%*

 

Emergency Room


Emergency Medical Transportation

John J Pershing: No Charge

MO Health COOP: 10%*

John J Pershing: No Charge

MO Health COOP: 10%*

10%*

 

10%*

 

10%*

 

10%*

 

Mental Health/Chemical Dependency

Inpatient


Office Visit

 

John J Pershing: No Charge

MO Health COOP: 10%*

John J Pershing: No Charge

MO Health COOP: 10%*

 

20%*

 

20%*

 

 

30%*

 

30%*

 

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

Greater than a $10 Copay or 10%*

Greater than a $40 Copay or 10%*

Greater than a $50 Copay or 10%*

20%*

Mail Order 90 Day Supply

Greater than a $10 Copay or 10%*

Greater than a $120 Copay or 10%*

Greater than a $120 Copay or 10%*

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 844-660-2445