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

 

$2,500

$5,000

 

 

 

Out-Of-Pocket Maximum

Individual

Family

 

$6,000

$12,000

 

 

 

Preventive Care

No Charge

 

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$10 Copay

$25 Copay

$25 Copay

 

 

 

 

Urgent Care Services

$30 Copay

 

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

 

 

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

 

 

Emergency Services

Emergency Room

Emergency Medical Transportation

 

$200 Copay, then 20%*

20%*

 

 

 

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$25 Copay

 

 

 

Prescription Drug Coverage

Generic

Formulary

Non-Formulary

Specialty

Retail 30 Day Supply

$5 Copay

$30 Copay

$60 Copay

20%* up to $250

Mail Order 90 day Supply

$10 Copay

$60 Copay

$120 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 1-888-806-3268