Planstin Medical Summary

1506 S Silicon Way Suite 2B, St. George, UT 84770 | 888-920-7526 | planstin.com OUTLINE | CARE+ COPAY 04 CARE+ COPAY Deductible Out-of-Pocket Max 1500 $1,500 Ind $3,000 Fam $3,100 Ind $6,500 Fam 2500 $2,500 Ind $5,000 Fam $5,100 Ind $10,500 Fam 3500 $3,500 Ind $7,000 Fam $7,100 Ind $14,500 Fam Service Copay Primary Care Visit $50 Urgent Care Visit $100 COPAYS WITH DEDUCTIBLE WAIVED 30% COINSURANCE Service Copay Specialist Care Visit $100 Emergency Care $500 PLANSTINRX Prescription Tier Retail (First Fill) Mail Order (All Refills) Tier 1: Generic $10 $20 Tier 2: Preferred Brand $50 $100 Tier 3: Non-Preferred Brand $100 $100 Tier 4: Specialty | 30% coinsurance after Rx deductible | $500 max paid per Rx, per month NO NETWORK COMPREHENSIVE COVERAGE Rx Deductible Rx Out-of-Pocket Max All Levels $1,000 Ind $2,000 Fam $1,200 Ind $2,100 Fam Accessible care at an affordable price. FAIR-PRICE HEALTHCARE With no network, youll have more provider options. The plan pays claims based on the most reasonable rates for your area. To learn more visit planstin.com/help-center . Your health plan covers essential health benefits and allows you to see specialists without a referral. There are no limits on pre-existing conditions for covered services, and the deductible is waived for copay services. Review your plan details, find plan documents, and get started with your benefits by scanning the code. PLAN SUMMARY Home delivery and significant discounts. Visit planstinrx.com to get started. PRESCRIPTIONS COPAYS PLAN OPTIONS