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

Buy Up Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$4,000

 

$4,000

$8,000

Out-of-Pocket Maximum

Individual

Family

 

$4,500

$9,000

 

$13,500

$27,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$60 Copay

30%*

 

50%*

50%*

50%*

Urgent Care Services

$75 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

30%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

30%*

30%*

30%*

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$40 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$20 Copay

$65 Copay

$100 Copay

30% Coinsurance

Mail Order 90 Day Supply

$60 Copay

$195 Copay

$300 Copay

Not Available

NOTE: * Coinsurance after deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

Base Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

$7,500

$15,000

Out-of-Pocket Maximum

Individual

Family

 

$6,500

$13,000

 

$15,000

$30,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$60 Copay

30%*

 

50%*

50%*

50%*

Urgent Care Services

$75 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

30%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

30%*

30%*

30%*

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$40 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$20 Copay

$65 Copay

$100 Copay

30% Coinsurance

Mail Order 90 Day Supply

$60 Copay

$195 Copay

$300 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 844-675-4352