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

Calendar Year Deductible

Individual

Family

 

$3,000

$6,000

 

$6,500

$13,000

Out-Of-Pocket Maximum

Individual

Family

 

$6,500

$13,000

 

$13,000

$26,000

Preventive Care

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Office Visit

 

$30 Copay

$50 Copay

$50 Copay

 

50%*

50%*

50%*

Urgent Care Services

$90 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Hospital Services Inpatient & Outpatient

20%*

50%*

Emergency Services

Emergency Room

Emergency Medical Transportation**

 

$250 Copay

20%*

 

$250 Copay

50%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

20%*

$30 Copay

 

50%*

50%*

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

 

$55 Copay

$55 Copay

$55 Copay

$55 Copay

$55 Copay

 

$55 Copay

$55 Copay

$55 Copay

$55 Copay

$55 Copay

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$15 Copay

$45 Copay

$85 Copay

$250 Copay

Mail Order 90 day Supply

$45 Copay

$135 Copay

$255 Copay

Not Covered

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 844-281-5216