Medical Benefits

Name: Heartland Community Health Center
Address: United States

	In-Network
Deductible (Ded.) (Individual/Family)	$2,500/$5,000
Member Coinsurance	20%
Out-of-Pocket Max (Individual/Family)	$5,000/$10,000
Primary Care Visit	$25 Copay
ACA Preventive Care	100% Covered
Specialist Visit	$25 Copay
Inpatient Hospital	Deductible + 20%
Outpatient Surgery	Deductible + 20%
Outpatient Diagnostics	100% Coverage to a combined max of $300/covered person, then subject to Deductible+Coinsurance
Urgent Care	Same as office visit copay
Emergency Room	$250 Copay + Deductible + 20%

	Per Pay Period Rate (24 Pay Periods)
Employee Only	$91.79
Employee + Spouse	$355.17
Employee + Child(ren)	$326.83
Employee + Family	$590.23

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	In-Network
Deductible (Ded.) (Individual/Family)	$5,000/$10,000
Member Coinsurance	100%
Out-of-Pocket Max (Individual/Family)	$6,350/$12,700
Primary Care Visit	Deductible
ACA Preventive Care	100% Covered
Specialist Visit	Deductible
Inpatient Hospital	Deductible
Outpatient Hospital	Deductible
Outpatient Diagnostics	Deductible
Urgent Care	Deductible
Emergency Room	Deductible

Prescription Drugs	In-Network
Tier 1	$15 Copay**
Tier 2	$50 Copay**
Tier 3	$75 Copay**
Specialty Preferred	$150**
Specialty Non-Preferred	20% to a maximum of $250**
	**Applicable copay after deductible has been met.