Page 22 - Revolution Health Plans Brochure 2024

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In-Network Benefits Glory EZ Banner EZ 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 No Deductible, No Copay
be paid absent of cost sharing.
Virtual Care / Telemedicine With Virtual Primary Care (VPC), members and their families receive access to a dedicated physician. The Freedom EZ Series provides traditional qualified
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 No Deductible, No Copay high deductible health plans (qHDHP) designed with
See enrollment materials for details. provider. specific advantages for employees and employers
EXPENSES ABOVE THIS LINE NOT SUBJECT TO DEDUCTIBLE EXPENSES ABOVE THIS LINE NOT SUBJECT TO DEDUCTIBLE starting, or with an established Health Savings
Plan Year Deductible Account. A Health Savings Account, or HSA, is a
Individual Only one deductible amount applies regardless of dependent status. $3,500 per Individual $5,000 per Individual tax favored savings account often described as a
Family $3,500 per Family $5,000 per Family medical IRA because of it’s similar (but enhanced) tax
Out of Pocket Maximum All in network covered cost sharing including copays, deductible and coinsurance combine to meet advantages. By moving to a qHDHP an employer and
Individual this OOP maximum. $5,000 per Individual $6,500 per Individual employee find premium savings which can be used to
Family $5,000 per Family $6,500 per Family
help fund an employee owned HSA. The combination
Professional Outpatient Office Visits These charges are billed by the physician for time spent with the patient. Office visits do not include of an HSA with a qHDHP leads to many advantages for
Primary Care charges for diagnostic, surgical or medical procedures performed by the physician or for diagnostic $20 Copay after the Deductible $20 Copay after the Deductible
Specialist services billed separately. $40 Copay after the Deductible $40 Copay after the Deductible the employee:
Mental Health & Substance Use Disorder $20 Copay after the Deductible $20 Copay after the Deductible • Tax deductible contributions into the HSA

Office Based Diagnostic Tests, Includes diagnostic tests performed in a physician’s office and billed by such physician or a $20 Copay after the Deductible $20 Copay after the Deductible
Labs & X-Ray freestanding non-hospital billed facility only. • Tax deferred growth of funds in the HSA

Outpatient Surgical, Diagnostic Includes outpatient services, such as miscellaneous medical procedures and supplies, diagnostic and • Tax free funds for payment of qualified medical
& Therapeutic Procedures therapeutic procedures and surgery at a physician’s office, freestanding surgical center or hospital expenses including copays, deductibles, dental,
Medical Services (when approved). 0% after the Deductible 0% after the Deductible vision and more (see IRS Sect 213(d)
Facility Charges 0% after the Deductible 0% after the Deductible
• Long term growth and monies used from an
Vision Annual Exam Only Any optometrist; member must submit claim for reimbursement. Copay waived for children under 5. $30 Copay after the Deductible $30 Copay after the Deductible HSA for medical expenses are always tax free
Physical, chiropractic, speech and occupational therapy. (Includes therapies performed in a provider’s • Unused funds remain in the account to continue
Short Term Rehabilitation Services $40 Copay after the Deductible $40 Copay after the Deductible
office or other non-hospital billed facility only). to grow
Emergency Services ER co-payment waived if admitted; $250 penalty for non-emergency use of a hospital emergency • Can be funded by the employer and/or employee
Hospital Emergency Room room. Urgent Care co-payments do not include charges for diagnostic, surgical, or medical $200 Copay after the Deductible $200 Copay after the Deductible
Urgent Care/Physician procedures. $20 Copay after the Deductible $20 Copay after the Deductible
Ambulance $40 Copay after the Deductible $40 Copay after the Deductible
Our Freedom EZ Series is specifically designed to make
Allergy Treatment this easy, efficient, and inexpensive while providing
Testing & Injections $20 Copay after the Deductible $20 Copay after the Deductible improved benefits. We accomplish this by providing
Serum $150 Copay after the Deductible $150 Copay after the Deductible
a single deductible regardless of dependent status,
Prescription Drug Coverage making it easy to understand, and communicate. In
Tier 1 Up to a 34-day supply may be purchased at retail for the listed copay. $0 after the Deductible $0 after the Deductible addition, this can serve to even out the employer
Tier 2 Up to a 90-day supply may be purchased at retail or by mail order for 2 copays. $20 after the Deductible $20 after the Deductible
Tier 3 $75 after the Deductible $75 after the Deductible contribution to a single level for each employee.
Tier 4 $150 after the Deductible $150 after the Deductible

Inpatient Hospitalization These tools and strategies can lead to long term
Medical Services & Facility 0% after the Deductible 0% after the Deductible savings for employers and employees while building
Anesthesiologist & Surgeon Fees 0% after the Deductible 0% after the Deductible
Mental Health & Substance Use Disorder 0% after the Deductible 0% after the Deductible additional retirement funds for many employees.
Home Health Care & 0% after the Deductible 0% after the Deductible
Skilled Nursing Facilities
Durable Medical Equipment 0% after the Deductible 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, and an Increased
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 Out Of POcket maxImum Of an addItIOnal $2,000/$4,000, and reImbursement lImItatIOns that may result In balance bIllIng. facIlIty charges are nOt netwOrk based. Please see vendOr
sPd Is the fInal determInatIOn Of all benefIts. Out-Of-netwOrk benefIts are subject tO usual and custOmary lImItatIOns. 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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