Summary Of Medical Benefits
Copay Plan
In-Network
Out-Of-Network
|
Embedded Deductible Employee Only Family |
$2,500 $5,000 |
$6,250 $12,500 |
|
Out-of-Pocket Maximum Employee Only Family |
$6,900 $13,800 |
$17,250 $34,500 |
|
Preventative Services |
No Charge |
40%* |
|
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
$20 Copay $40 Copay 50%* |
40%* 40%* 40%* |
|
Urgent Care Services |
$50 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 Services Emergency Medical Transportation |
$400 Copay, then 20%* 20%* |
$400 Copay, then 20%* 20%* |
|
Mental Health Inpatient Office Visit |
20%* $20 Copay |
40%* 40%* |
|
Prescription Drug Coverage Generic Preferred Brand Non-Preferred Brand Specialty |
$15 Copay $40 Copay $80 Copay 25% Coinsurance up to $350 |
$38 Copay $120 Copay $240 Copay Not Available |
If you prefer talking with a HealthEZ representative, call 844-302-7789