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 1

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$1,000

$2,000

 

$5,000

$10,000

Coinsurance

20%

40%

Out-Of-Pocket Maximum

Employee Only

Family

 

$3,500

$7,000

 

$8,000

$16,000

Preventive Care

100% Covered

40%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

$40 Copay

$40 Copay

20%*

 

40%*

40%*

40%*

Hospital Services

20%*

40%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

20%*

20%*

 

40%*

40%*

Urgent Care Services

$40 Copay

40%*

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

ental Health - Psychiatrist, ongoing session

 

$40 Copay

$40 Copay

$40 Copay

$40 Copay

$40 Copay

 

$40 Copay

$40 Copay

$40 Copay

$40 Copay

$40 Copay

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

20%*

$40 Copay

 

40%*

40%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$15 Copay

$50 Copay

$100 Copay

20% up to $200/prescription

Mail Order 90 Day Supply

$30 Copay

$100 Copay

$200 Copay

Not Available

* After deductible

 

 

** True emergencies covered at in-network level

 

 

HSA Plan 1

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$3,500

$7,000

 

$17,500

$17,500

Out-Of-Pocket Maximum

Employee Only

Family

 

$3,500

$7,000

 

$17,500

$24,000

Preventive Care

No Charge

50%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

0%*

0%*

0%*

 

50%*

50%*

50%*

Hospital Services

0%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

0%*

0%*

 

50%*

50%*

Urgent Care Services

0%*

50%*

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

ental Health - Psychiatrist, ongoing session

 

$40 Copay After Deductible

$40 Copay After Deductible

$40 Copay After Deductible

$40 Copay After Deductible

$40 Copay After Deductible

 

$40 Copay After Deductible

$40 Copay After Deductible

$40 Copay After Deductible

$40 Copay After Deductible

$40 Copay After Deductible

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

0%*

0%*

 

50%*

50%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Available

* After deductible

 

 

** True emergencies covered at in-network level

 

 


If you prefer talking with a HealthEZ representative, call 844-623-5047