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 1

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,500

$7,000

 

$7,000

$14,000

Out-of-Pocket Maximum

Individual

Family

 

$8,150

$16,300

 

$16,300

$32,600

Preventative Services

No Charge

50%*

Office Visits

Primary Office Visit under 19 years old

Primary Office Visit over 19 years old

Specialist Office Visit

Chiropractic Visit

 

No Charge

$25 Copay

$75 Copay

$25 Copay

 

50%*

50%*

50%*

50%*

Urgent Care Services

$50 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

$300 Copay, then 20%*

20%*

$300 Copay, then 20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$75 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$35 Copay

$75 Copay

$250 Copay

Mail Order 90 Day Supply

$25 Copay

$87.50 Copay

$187.50 Copay

Not Available

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 855-535-4495