Plan Details

Plan Details

Your healthcare coverage is important to us. Age, family status, medical conditions, hobbies, lifestyle and a myriad of other factors will help you determine if you need a lot or a very little amount of health coverage. This summary will help you understand your plan and its coverage.

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Summary of Medical Benefits

Copay Plan

In-Network

Out-of-Network

Embedded Deductible

Individual

Family

 

$1,500

$4,000

 

$2,000

$6,000

Out-of-Pocket Maximum

Individual

Family

 

$3,000

$6,500

 

$3,000

$10,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$50 Copay

50% Coinsurance

 

40%*

40%*

50% Coinsurance

Urgent Care Services

$100 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

$300 Copay

20%*

$300 Copay

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$50 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$40 Copay

$75 Copay

Not Covered

Mail Order 90 Day Supply

$25 Copay

$87.50 Copay

$150 Copay

Not Covered

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

If you prefer talking with a HealthEZ representative, call 844-855-0622