Page 13 - Revolution Health Plans Brochure 2024

Health Plan Options
H eal th P l an O p tio ns P a tr io t P l an S er ies ( HR A EZ )
Patriot Plan Series (HRA EZ)

In-Network Benefits Washington HRA EZ Information

Preventive Care Under PPACA Charges for preventive care as per PPACA on the effective date of the plan provide for certain benefits to No Deductible, No Copay
be paid absent of cost sharing.
The Patriot HRA EZ Series provides traditional plans designed
Virtual Care / Telemedicine With Virtual Primary Care (VPC), members and their families receive access to a dedicated physician. with specific advantages for use with a Health Reimbursement
Full Virtual Primary, Urgent and Behavioral Health. Virtual Preventive, Urgent, and Behavioral Health are covered at a $0 Copay when using a Recuro No Deductible, No Copay
See enrollment materials for details. provider. Arrangement (HRA). An HRA is a plan whereby an employer, as plan
Professional Outpatient Office Visits These charges are billed by the physician for time spent with the patient. Office visits do not include sponsor, purchases a health benefit plan for employees and provides
Primary Care charges for diagnostic, surgical or medical procedures $20 Copay an additional reimbursement for portions not covered by the health
Specialist performed by the physician or for diagnostic services billed separately. $40 Copay plan design. Most often this is a simple reimbursement of some
Mental Health & Substance Use Disorder $20 Copay
Office Based Diagnostic Tests, Includes diagnostic tests performed in a physician’s office and billed by such physician or a freestanding $20 Copay portion of the health plan deductible.
Labs & X-Ray non-hospital billed facility only.
Outpatient Surgical, Diagnostic Our HRA EZ Series is specifically designed to make this easy, efficient
& Therapeutic Procedures Includes outpatient services, such as miscellaneous medical procedures and supplies, diagnostic and and inexpensive while providing enhanced benefits without added
therapeutic procedures and surgery at a physician’s
Medical Services office, freestanding surgical center or hospital (when approved). $60 Copay administration fees.
Facility Charges $60 Copay
Any optometrist; member must submit claim for reimbursement.
Vision Annual Exam Only $30 Copay
Copay waived for children under 5. With HRA EZ:
Short Term Rehabilitation Services Physical, chiropractic, speech and occupational therapy. (Includes therapies performed in a provider’s $40 Copay • Easy to understand with the same deductible amount
office or other non-hospital billed facility only).
for individual or families
Emergency Services
Hospital Emergency Room ER copayment waived if admitted; $250 penalty for non-emergency use of a hospital emergency room. $200 Copay • Easy copays rather than applying a deductible

Urgent Care/Physician Urgent Care copayments do not include charges for diagnostic, surgical, or medical procedures. $20 Copay
Ambulance $40 Copay • Easy for employees to use
Allergy Treatment • Easy for employers to fund - only the less frequent
Testing & Injections $20 Copay procedures apply to the deductible
Serum $150 Copay
• Easy to provide better benefits for less money
Prescription Drug Coverage
Tier 1 Up to a 34-day supply may be purchased at retail for the listed copay. $0 Copay
Tier 2 Up to a 90-day supply may be purchased at retail or by mail order for 2 copays. $20 Copay
Tier 3 $75 Copay
Tier 4 $150 Copay

EXPENSES ABOVE THIS LINE NOT SUBJECT TO DEDUCTIBLE
Plan Year Deductible $2,500 Deductible
Individual Only one deductible amount applies regardless of dependent status. $2,500 Deductible
Family
Deductible & Coinsurance Maximum Copays do not apply to the deductible and coinsurance maximum. However, copays combined with the
Individual deductible and coinsurance maximum do apply to an In Network Out of Pocket maximum of $7,000 $2,500 Deductible
Family regardless of dependent status. $2,500 Deductible
Inpatient Hospitalization
Medical Services & Facility 0% after the Deductible
Anesthesiologist & Surgeon Fees 0% after the Deductible
Mental Health & Substance Use Disorder 0% after the Deductible
Home Health Care & 0% after the Deductible
Skilled Nursing Facilities
Durable Medical Equipment 0% after the Deductible

In PPO Plans: when receIvIng care frOm nOn-netwOrk PrOvIders, all benefIts are subject tO the deductIble, and an addItIOnal 20% cOInsurance, and an Increased Out Of POcket In PPO rePlacement Plans: when receIvIng care frOm nOn-netwOrk PrOvIders, all benefIts are subject tO the deductIble, and an addItIOnal 20% cOInsurance,
maxImum Of an addItIOnal $2,000/$4,000, and reImbursement lImItatIOns that may result In balance bIllIng. Please refer tO the summary Plan descrIPtIOn (sPd) fOr detaIls. the and an Increased Out Of POcket maxImum Of an addItIOnal $2,000/$4,000, and reImbursement lImItatIOns that may result In balance bIllIng. facIlIty charges
sPd Is the fInal determInatIOn Of all benefIts. Out-Of-netwOrk benefIts are subject tO usual and custOmary lImItatIOns. are nOt netwOrk based. Please see vendOr sPecIfIc detaIls regardIng benefIt reImbursement, as selected. Please refer tO the summary Plan descrIPtIOn (sPd) fOr
detaIls. the sPd Is the fInal determInatIOn Of all benefIts.
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