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

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