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Schedule of Benefits (Cost When You Use the Coverage)
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MESSA Choices Plan
In-Network
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MESSA ABC Plan 1
In-Network
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Essentials by MESSA
In-Network
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Deductible
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$500 Individual
$1,000 Family
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$1,600 Single
$3,200 2-Person & Family
|
$375 Individual
$750 Family
|
|
Coinsurance
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0%
|
0%
|
20%
|
|
Office Visit
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$20 Copay After Deductible
|
Covered 100% After Deductible
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$25 Copay After Deductible, and 20% Coinsurance After Deductible
|
|
Online Visit
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$20 Copay
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Covered 100% After Deductible
|
$10 Copay After Deductible
|
|
Emergency Room
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$50 Copay and Deductible
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Covered 100% After Deductible
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$200 Copay and Deductible, and 20% Coinsurance After Deductible
|
|
Urgent Care
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$25 Copay and Deductible
|
Covered 100% After Deductible
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$50 Copay and Deductible, and 20% Coinsurance After Deductible
|
|
Prescription Drugs
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$2 or $10 Generic
$20 or $40 Brand
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After Deductible:
Free, $2 or $10 Generic
Free, $20 or $40 Brand
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$10 Generic
20% Coinsurance Brand ($100 max)
|
|
Health Savings Account (H.S.A.)
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Not Eligible for H.S.A.
|
H.S.A. Eligible
|
Not Eligible for H.S.A.
|
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Out of Pocket Maximum
(The most you could pay in a year for covered services and prescriptions)
|
$2,500 Individual
$5,000 Family
|
$2,600 Individual
$5,200 Family
|
$9,450 Individual
$18,900 Family
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