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

Deductible

Employee Only

Family

 

$2,000

$4,000

 

$7,000

$14,000

Out-Of-Pocket Maximum

Employee Only

Family

 

$5,000

$8,500

 

$25,650

$51,300

Preventive Care

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$30 Copay

30%*

 

50%*

50%*

50%*

Urgent Care Services

$60 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

$300 Copay

30%*

50%*

50%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

30%*

$30 Copay

 

50%*

50%*

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

 

100% Covered

$85 Copay

$50 Copay

$50 Copay

$50 Copay

 

100% Covered

$85 Copay

$50 Copay

$50 Copay

$50 Copay

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$15 Copay

$45 Copay

$60 Copay

$150 Copay

Mail Order 90 day Supply

$30 Copay

$90 Copay

$120 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 844-676-0362