PEAK PPO GOLD HDHP

Mountain Health CO-OP

GoldHSA eligible

Ind. deductible: $4,000
Family deductible: $4,000
Ind. OOP max: $4,000
Family OOP max: $4,000

Other cost-sharing reduction variants for this plan:

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$541	—
30	$614	—
40	$692	—
50	$966	—
60	$1,469	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	0.00% Coinsurance after deductible

Specialist

Benefit	In-network
Specialist Visit	0.00% Coinsurance after deductible

Hospital

Benefit	In-network
Emergency Room Services	0.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	0.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	0.00% Coinsurance after deductible
Urgent Care Centers or Facilities	0.00% Coinsurance after deductible

Pharmacy

Benefit	In-network
Generic Drugs	0.00% Coinsurance after deductible
Non-Preferred Brand Drugs	0.00% Coinsurance after deductible
Preferred Brand Drugs	0.00% Coinsurance after deductible
Specialty Drugs	0.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	0.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	0.00% Coinsurance after deductible

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	0.00% Coinsurance after deductible
Acupuncture	0.00% Coinsurance after deductible
Allergy Testing	0.00% Coinsurance after deductible
Bariatric Surgery	Not covered
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	Not covered
Chemotherapy	0.00% Coinsurance after deductible
Chiropractic Care	0.00% Coinsurance after deductible
Cosmetic Surgery	0.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care	0.00% Coinsurance after deductible
Dental Check-Up for Children	Not covered
Diabetes Education	0.00% Coinsurance after deductible
Dialysis	0.00% Coinsurance after deductible
Durable Medical Equipment	0.00% Coinsurance after deductible
Emergency Transportation/Ambulance	0.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	0.00% Coinsurance after deductible
Hearing Aids	Not covered
Home Health Care Services	0.00% Coinsurance after deductible
Hospice Services	0.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)	0.00% Coinsurance after deductible
Infertility Treatment	0.00% Coinsurance after deductible
Infusion Therapy	0.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	0.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	0.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	Not covered
Nutritional Counseling	0.00% Coinsurance after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	0.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	0.00% Coinsurance after deductible
Outpatient Rehabilitation Services	0.00% Coinsurance after deductible
Prenatal and Postnatal Care	0.00% Coinsurance after deductible
Private-Duty Nursing	Not covered
Prosthetic Devices	0.00% Coinsurance after deductible
Radiation	0.00% Coinsurance after deductible
Reconstructive Surgery	0.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	0.00% Coinsurance after deductible
Rehabilitative Speech Therapy	0.00% Coinsurance after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No charge
Routine Foot Care	0.00% Coinsurance after deductible
Skilled Nursing Facility	0.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	0.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	0.00% Coinsurance after deductible
Transplant	0.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	Not covered
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	0.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 1 geographic area.