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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

Deductible

Individual

Family

 

$500

$1,500

 

$1,000

$3,000

Out-of-Pocket Maximum

Individual

Family

 

$2,500

$7,500

 

$5,000

$15,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$40 Copay

20%*

 

40%*

40%*

40%*

Urgent Care Services

20%*

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 Room

Emergency Medical Transportation

$150 Copay

20%*

$150 Copay

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$40 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

No Charge

$35 Copay

$75 Copay

Not Covered

Mail Order 90 Day Supply

No Charge

$70 Copay

$150 Copay

Not Covered

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 844-288-5707