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

$500 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$500

$500

$1,000

 

$1,000

$1,000

$2,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$2,500

$2,500

$5,000

 

$5,000

$5,000

$10,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

25%*

25%*

25%*

 

50%*

50%*

50%*

Urgent Care Services

25%*

50%*

Complex Imaging: MRI/CT/PET Scans

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

25%*

25%*

25%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

25%*

25%*

 

50%*

50%*

Prescription Drug Coverage

Preventive Prescriptions

Expanded Preventive - Generic

Expanded Preventive - Preferred Brand

Generic

Preferred brand

Non-preferred brand

Specialty Drugs

Retail 30 Day Supply

No Charge

Not Covered

Not Covered

25%*

25%*

25%*

25%*

Mail Order 90 Day Supply

No Charge

Not Covered

Not Covered

25%*

25%*

25%*

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 844-302-7783