Skip to content

The Essentials

$6,500

Deductible*

$13,000

Deductible per family

$6,800

Out-of-Pocket Maximum

$0*

15%

tier-1 preferred generic drugs

*Deductible cost for in-network care. 

Hospital Network: Network Provider Finder for all types of providers
Plan Type: PPO
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.

Plan Details

Services

Preventive Care Services

In-Network

Out-of-Network

Preventive Health Screenings

In-Network

100% of the Allowable Fee*

Out-of-Network

60% after deductible

Medical + Hospital Services

In-Network

Out-of-Network

Physician Office Visits

In-Network

Non-specialist – $40 copay
Specialist – $75 copay

Out-of-Network

60% after deductible

Inpatient Facility

In-Network

40% after deductible

Out-of-Network

60% after deductible

Outpatient Facility

In-Network

40% after deductible

Out-of-Network

60% after deductible

Virutal Health:
Doctor on Demand

In-Network

$20 copay

Out-of-Network

Not Available

Urgent care services at Clinic

In-Network

$110 copay

Out-of-Network

60% after deductible

Emergency room services

In-Network

50% after deductible

Out-of-Network

50% 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

Pharmacy

See if your drugs are covered

Prescription Drugs*

In-Network

Out-of-Network

Tier 1:
Preferred Generic Drugs

In-Network

15%

Out-of-Network

60% after deductible

Tier 2:
Non-Preferred Generic & Preferred Brand Drugs

In-Network

30%

Out-of-Network

60% after deductible

Tier 3:
Non-Preferred Brand Drugs

In-Network

40%

Out-of-Network

60% after deductible

Tier 4:
Specialty Drugs

In-Network

50% after deductible

Out-of-Network

60% 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

Tier 1:
Preferred Generic Drugs

In-Network

10%

Out-of-Network

60% after deductible

Tier 2:
Non-Preferred Generic & Preferred Brand Drugs

In-Network

30%

Out-of-Network

60% after deductible

Tier 3:
Non-Preferred Brand Drugs

In-Network

40%

Out-of-Network

60% after deductible

Tier 4:
Specialty Drugs

In-Network

Not Available

Out-of-Network

Not Available

* 90-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.

Mental Health

Mental health/Dependency Services

In-Network

Out-of-Network

Inpatient/other Outpatient Facility Services

In-Network

Inpatient – 40% after deductible

Other outpatient – 40% after deductible

 

Out-of-Network

60% after deductible

Office Visits

In-Network

$40 copay

Out-of-Network

60% after deductible

Other Services

Other Services

In-Network

Out-of-Network

Chiropractic Care

Maximum Number of Office Visits per Calendar Year 20 visits

In-Network

$75 copay

Out-of-Network

60% after deductible

Convalescent Home Services

Maximum Number of Days per Calendar Year-60 days

In-Network

40% after deductible

Out-of-Network

60% after deductible

Durable Medical Equipment

Rental (up to the purchase price), Purchase and Repair and Replacement of Durable Medical Equipment.

In-Network

40% after deductible

Out-of-Network

60% after deductible

Laboratory Services

In-Network

50% after deductible

Out-of-Network

60% after deductible

Transplant Services

In-Network

40% after deductible

Out-of-Network

60% after deductible

Reimbursements

Dental Exam, Cleaning, Fluoride

$100 reimbursement to apply to exam, cleaning and fluoride once per year.

Vision Exam

$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.

Refer to your Member Guide.

Frequently Asked Questions & Terminology

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.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.

All-Purpose Feedback Form

1. Submit unlimited forms
2. DO NOT FORGET to enter the page name.