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.

Summary Of Medical Benefits

Copay Plan

In-Network

Out-Of-Network

Deductible

Individual

Family

 

$500

$1,000

 

$3,000

$6,000

Out-Of-Pocket Maximum

Individual

Family

 

$3,000

$6,000

 

$10,000

$20,000

Preventive Care

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$20 Copay

$20 Copay

 

40%*

40%*

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Emergency Services

Emergency Room

Emergency Medical Transportation

 

$250 Copay

20%*

 

$250 Copay

20%*

Mental Health / Chemical Dependency

Inpatient

Office Viist

 

20%*

$20 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$15 Copay

$35 Copay

$65 Copay

$200 Copay

Mail Order 90 day Supply

$30 Copay

$70 Copay

$130 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 844-801-1911