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

Deductible

Individual

Individual under Family

Family

 

$500

$500

$1,000

 

$3,000

$3,000

$6,000

Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$1,000

$1,000

$2,500

 

$5,000

$5,000

$12,500

Preventive Care Services

No Charge

30%*

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$20 Copay

$40 Copay

$40 Copay

30%*

30%*

30%*

Urgent Care Services

$50 Copay

$50 Copay

Complex Imaging: MRI/CT/PET Scans

10%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$250 Copay, then 10%*

10%*

 

$500 Copay, then 30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

$250 Copay, then 10%*

10%*

 

$500 Copay, then 30%*

30%*

Emergency Room Services

Emergency Medical Transportation

$100 Copay

10%*

$100 Copay

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$250 Copay, then 10%*

$20 Copay

 

$500 Copay, then 30%*

30%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Diabetic Medication & Supplies

Retail 30 Day Supply

$5 Copay

$15 Copay

$35 Copay

$50 Copay

No Charge

Mail Order 90 Day Supply

$5 Copay

$15 Copay

$35 Copay

$50 Copay

No Charge

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 866-746-4056