*Deductible cost for in-network care.Â
Hospital Network: St. Alphonsus
Plan Type: POS
HSA Eligible: No
Lifetime Maximum Limit: No
Coverage Overview:
Affordable coverage that includes annual wellness and preventive care. Peace of mind that you have access to a select network of dedicated providers.
Preventive Care Services
In-Network
Out-of-Network
In-Network
100% of the Allowable Fee*
Out-of-Network
0% after deductible
Medical + Hospital Services
In-Network
Out-of-Network
In-Network
First 3 visits 0%
then 0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
*Preventive Health Care Services for health care screenings or preventive purposes submitted with a routine diagnosis will be covered at 100% of the Allowable Fee.
This means that these Benefits are not subject to the Deductible, Coinsurance, Copayments, or Annual Out-of-Pocket Maximum when services are provided by an In-Network provider.
However, if Preventive Health Care Services are rendered for an established medical condition or by a Non-In-Network provider, the Preventive Health Care Services provided will be subject to the Deductible, Coinsurance, Copayments, and Annual Out-of-Pocket Maximum
Prescription Drugs*
In-Network
Out-of-Network
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
*Retail Pharmacy Benefit (30-day supply)
If you choose a higher Tier drug when a lower Tier drug is available, you must pay an ancillary charge in addition to the deductible and/or coinsurance, as applicable.
Mail Order Maintenance*
In-Network
Out-of-Network
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
Not Available
Out-of-Network
Not Available
* 90-day supplyÂ
If you choose a higher Tier drug when a lower Tier drug is available, you must pay an ancillary charge in addition to the deductible and/or coinsurance, as applicable.
Mental health/Dependency Services
In-Network
Out-of-Network
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
First 3 visits 0%
then 0% after deductible
Out-of-Network
0% after deductible
Other Services
In-Network
Out-of-Network
Maximum Number of Office Visits per Calendar Year 20 visits
In-Network
0% after deductible
Out-of-Network
0% after deductible
Maximum Number of Days per Calendar Year-60 days
In-Network
0% after deductible
Out-of-Network
0% after deductible
Rental (up to the purchase price), Purchase and Repair and Replacement of Durable Medical Equipment.
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
In-Network
0% after deductible
Out-of-Network
0% after deductible
$100 reimbursement to apply to exam, cleaning and fluoride once per year.
$60 reimbursement to apply to one routine exam per year.
Deductible and coinsurance apply to all services listed below, unless otherwise noted.
There is no lifetime maximum benefit limit for this plan.
This is only a summary of benefits.
Benefits and general provisions described herein are subject to the terms of the Member Guide.
Prior Authorization is not a guarantee of payment but is recommended for some services, supplies, treatments, and prescription drugs to help the Member identify potential expenses, payment reductions, or claim denials that may occur if these proposed services are not Medically Necessary or not a Covered Medical Expense.
Your pla deductible is the fixed dollar amount of Covered Medical Expenses that you must incur for certain Covered Benefits before MOUNTAIN HEALTH CO-OPbegins paying benefits for them. The Deductible must be satisfied each Calendar Year by each Covered Person, except as provided under Family Deductible L provision. The Deductible is shown in the Schedule of Benefits. Only the Allowable Fee for Covered Medical Expenses is applied to the Deductible. The following do not apply towards satisfaction of the Deductible: (1) services, treatments or supplies that are not covered under this Policy; and (2) amounts billed by Out-of-Network Providers, which include the Out-of-Network Provider Differential.
