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

Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$800

$800

$2,400

 

$2,400

$2,400

$7,200

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$6,000

$6,000

$12,000

 

$12,000

$12,000

$24,000

Preventive Care Services

No Charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$40 Copay

20%*

 

30%*

30%*

30%*

Urgent Care Services

$50 Copay

30%*

Complex Imaging: MRI/CT/PET Scans

20%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

30%*

30%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$150 Copay

20%*

20%*

 

$150 Copay

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$40 Copay

 

30%*

30%*

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 844-839-6738