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

Calendar Year Deductible

Employee Only

Family

 

$5,000

$10,000

 

Not Covered

Not Covered

Coinsurance

30%*

Not Covered

Out-Of-Pocket Maximum

Employee Only

Family

 

$7,150

$14,300

 

Not Covered

Not Covered

Preventive Care

100% Covered

Not Covered

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

$35 Copay

$50 Copay

30%*

 

Not Covered

Not Covered

Not Covered

Hospital Services

30%*

Not Covered

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$250 Copay

30%*

 

Not Covered

Not Covered

Urgent Care Services

$75 Copay

Not Covered

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

30%*

$50 Copay

 

Not Covered

Not Covered

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$20 Copay

$50 Copay

$75 Copay

30%

 

$40 Copay

$100 Copay

$150 Copay

Not Available

* After deductible

 

 

** True emergencies covered at in-network level

 

 


If you prefer talking with a HealthEZ representative, call 844-660-2459