Summary Of Medical Benefits
Copay Plan 1
In-Network
Out-Of-Network
|
Calendar Year Deductible Employee Only Family |
$2,000 $4,000 |
$7,000 $14,000 |
|
Coinsurance |
30% |
50% |
|
Out-Of-Pocket Maximum Employee Only Family |
$5,000 $8,500 |
$25,650 $51,300 |
|
Preventive Care |
100% Covered |
50%* |
|
Office Visits Primary Services Specialist Services Chiropractic Services |
$30 Copay $30 Copay $50 Copay |
50%* 50%* 50%* |
|
Hospital Services |
30%* |
50%* |
|
Emergency Services** Emergency Room Emergency Medical Transportation |
$300 Copay 30%* |
50%* 50%* |
|
Urgent Care Services |
$60 Copay |
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 |
|
Mental Health / Chemical Dependency Inpatient Outpatient |
30%* $30 Copay |
50%* 50%* |
|
|
Retail 30 Day Supply |
Mail Order 90 day Supply |
|
Prescription Drug Coverage Generic Preferred brand Non-preferred brand Specialty |
$15 Copay $45 Copay $60 Copay $150 Copay |
$30 Copay $90 Copay $120 Copay Not Available |
|
* After deductible |
|
|
|
** True emergencies covered at in-network level |
|
|
If you prefer talking with a HealthEZ representative, call 844-676-0362