Plan Details

Not all coverage is the right coverage.

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

Family

 

$2,000

$4,000

 

$3,000

$6,000

Out-Of-Pocket Maximum

Individual

Family

 

$6,000

$12,000

 

$11,000

$22,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$25 Copay

$25 Copay

 

40%*

40%*

40%*

Urgent Care Services

$25 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 Services**

Emergency Room

Emergency Medical Transportation

 

$250 Copay

20%*

 

40%*

40%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$25 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$35 Copay

$70 Copay

$10/ $35/ $70 Copay

Mail Order 90 day Supply

$30 Copay

$105 Copay

$210 Copay

Not Available

NOTE: * Coinsurance After Deductible

** True emergencies covered at in-network level

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

 

 

 

 

 

 


If you prefer talking with a HealthEZ representative, call 1-844-801-1913