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

$5,000 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$5,000

$5,000

$10,000

 

$12,000

$12,000

$24,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$8,000

$8,000

$16,000

 

$24,000

$24,000

$48,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$75 Copay

$100 Copay

$100 Copay

 

40%*

40%*

40%*

Urgent Care Services

$125 Copay

$125 Copay

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

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$500 Copay, then 20%*

20%*

20%*

 

$500 Copay, then 20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$75 Copay

 

40%*

40%*

Prescription Drug Coverage

Preventive Prescriptions

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

No Charge

$35 Copay

$150 Copay

$300 Copay

30% Coinsurance up to $750

Mail Order 90 Day Supply

No Charge

$105 Copay

$450 Copay

$900 Copay

Not Covered

NOTE: * Coinsurance after deductible

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

 

 

 

 

$5,000 HSA Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$5,000

$5,000

$10,000

 

$12,000

$12,000

$24,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$8,000

$8,000

$16,000

 

$24,000

$24,000

$48,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

10%*

10%*

10%*

 

40%*

40%*

40%*

Urgent Care Services

10%*

10%*

Complex Imaging: MRI/CT/PET Scans

10%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

40%*

40%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

10%*

10%*

10%*

 

10%*

10%*

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

10%*

 

40%*

40%*

Prescription Drug Services

Preventive Prescriptions

Expanded Preventive - Generic

Expanded Preventive – Preferred Brand

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

No Charge

No Charge

No Charge

10%*

10%*

10%*

10%*

Mail Order 90 Day Supply

No Charge

No Charge

No Charge

10%*

10%*

10%*

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 855-290-1412