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

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$2,500

$5,000

 

$10,000

$20,000

Coinsurance

0%

40%

Out-Of-Pocket Maximum

Employee Only

Family

 

$2,500

$10,000

 

$10,000

$40,000

Preventive Care

100% Covered

40%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

$30 Copay

$50 Copay

0%*

 

40%*

40%*

40%*

Hospital Services

0%*

40%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$250 Copay

0%*

 

40%*

40%*

Urgent Care Services

$45 Copay

40%*

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

 

100% Covered

$85 Copay

100% Covered

100% Covered

100% Covered

 

100% Covered

$85 Copay

100% Covered

100% Covered

100% Covered

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

0%*

$30 Copay

 

40%*

40%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$10 Copay

$40 Copay

$80 Copay

Not available

 

$25 Copay

$100 Copay

$200 Copay

Not Available

* After deductible

 

 

** True emergencies covered at in-network level

 

 


If you prefer talking with a HealthEZ representative, call 1-844-204-3760