Plan Details

Summary of Medical Benefits

Medical PPO Plan

Katy Trail Community Health
Missouri Health Cooperative

HealthLink
Freedom Select

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

$4,000

$8,000

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

$5,000

$10,000

$20,000

$60,000

Preventive Care Services

No Charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

No Charge

Not Available

$40 Copay

$80 Copay

30%*

Urgent Care Services

No Charge

$40 Copay

30%*

Complex Imaging: MRI/CT/PET Scans

No Charge

$400 Copay

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

No Charge

20%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

No Charge

20%*

30%*

Emergency Room

Facility Fee

Physician Fee

Medical Transportation

Not Applicable

$200 Copay

No Charge

$200 Copay

20% Coinsurance

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

Not Available

No Charge

20%*

$80 Copay

30%*

NOTE: * Coinsurance after deductible

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

Prescription Drug Coverage

Katy Trail Pharmacy & Prescriber: 30 day/90 day

Katy Trail Pharmacy & Non-Katy Trail Prescriber: 30 day/90 day

Non-Katy Trail Pharmacy:
30 day/90 day

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Preferred Specialty Drugs

Non-Preferred Specialty Drugs

No Charge/No Charge

No Charge/Not Covered

$5 Copay/$10 Copay

$20 Copay/$40 Copay

$50 Copay/$100 Copay

20% Coinsurance up to $500/Not Covered

30% Coinsurance up to $500/Not Covered

$20 Copay/$50 Copay

$45 Copay/$113 Copay

$80 Copay/$200 Copay

20% Coinsurance up to $500/Not Covered

30% Coinsurance up to $500/Not Covered

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