Mountain Health CO-OP - Link Silver
Primary Care Visit
$10 Copay after deductible
40% Coinsurance after deductible
Specialist Visit
$35 Copay after deductible
40% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
$10 Copay after deductible
40% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
40% Coinsurance after deductible
Laboratory Outpatient and Professional Services
20% Coinsurance after deductible
40% Coinsurance after deductible
X-rays and Diagnostic Imaging
20% Coinsurance after deductible
40% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
20% Coinsurance after deductible
40% Coinsurance after deductible
Generic Drugs
$5 Copay
$5 Copay
Preferred Brand Drugs
$15 Copay
$15 Copay
Non-Preferred Brand Drugs
$40 Copay
$40 Copay
Specialty Drugs
$65 Copay
$65 Copay
Outpatient Facility Fee
20% Coinsurance after deductible
40% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
20% Coinsurance after deductible
40% Coinsurance after deductible
Emergency Room Services
$100 Copay after deductible
$100 Copay after deductible
Emergency Transportation/Ambulance
20% Coinsurance after deductible
40% Coinsurance after deductible
Urgent Care
20% Coinsurance after deductible
40% Coinsurance after deductible
Inpatient Hospital Services
20% Coinsurance after deductible
40% Coinsurance after deductible
Inpatient Physician and Surgical Services
20% Coinsurance after deductible
40% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
$10 Copay after deductible
40% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
20% Coinsurance after deductible
40% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
$10 Copay after deductible
40% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
20% Coinsurance after deductible
40% Coinsurance after deductible
Prenatal and Postnatal Care
20% Coinsurance after deductible
40% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
20% Coinsurance after deductible
40% Coinsurance after deductible
Home Healthcare Services
20% Coinsurance after deductible
40% Coinsurance after deductible
Outpatient Rehabilitation Services
20% Coinsurance after deductible
40% Coinsurance after deductible
Habilitation Services
20% Coinsurance after deductible
40% Coinsurance after deductible
Skilled Nursing Facility
20% Coinsurance after deductible
40% Coinsurance after deductible
Durable Medical Equipment
20% Coinsurance after deductible
40% Coinsurance after deductible
Hospice Services
20% Coinsurance after deductible
40% Coinsurance after deductible
Chiropractic Care
$35 Copay after deductible
40% Coinsurance after deductible
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
20% Coinsurance after deductible
40% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
20% Coinsurance after deductible
40% Coinsurance after deductible
Well Baby Visits and Care
No Charge
40% Coinsurance after deductible
Allergy Testing
20% Coinsurance after deductible
40% Coinsurance after deductible
Diabetes Education
20% Coinsurance after deductible
40% Coinsurance after deductible
Nutritional Counseling
20% Coinsurance after deductible
40% Coinsurance after deductible
Eye Exam for Children
No Charge
25% Coinsurance
Eye Glasses for Children
No Charge
25% Coinsurance
Accidental Dental
20% Coinsurance after deductible
40% Coinsurance after deductible
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
Not covered
Not covered
Dental Check Up (Child)
Not covered
Not covered
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
Not covered
Not covered
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
Not covered
Not covered
Routine Dental Services (Adult)
Not covered
Not covered