Plan Details

Plan Details

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 1

In-Network

Out-of-Network

Calendar Year Deductible

Employee only

Family

 

$4,000

$8,000

 

$10,000

$20,000

Coinsurance

0%

50%

Out-of-Pocket Maximum

Employee only

Family

 

$4,000

$8,000

 

$20,000

$40,000

Preventative Care

100% Covered

50%* after Deductible

Office Visits

Primary Services

Specialist Services

Chiropractor Services

 

$25 Copay

$25 Copay

$50 Copay

 

50%* after Deductible

50%* after Deductible

50%* after Deductible

Hospital Services

0%* after Deductible

50%* after Deductible

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$500 Copay

0%* after Deductible

 

50%* after Deductible

50%* after Deductible

Urgent Care Services

$40 Copay

50%* after Deductible

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

 

100% Covered

Not Covered

Not Covered

Not Covered

Not Covered

 

100% Covered

Not Covered

Not Covered

Not Covered

Not Covered

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

0%* after Deductible

$25 Copay

 

50%* after Deductible

50%* after Deductible

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$20 Copay

$40 Copay

$60 Copay

$250 Copay

Mail Order 90 Day Supply

$40 Copay

$80 Copay

$120 Copay

Not available

*Coinsurance

** Covered as in-network in true-emergency

 

 

 

 

If you prefer talking with a HealthEZ representative, call 844-281-5224