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
Deductible
Individual
Individual under Family
Family
$1,250
$3,750
$2,250
$6,750
Out-Of-Pocket Maximum
$4,250
$12,750
Preventive Care Services
Employee
Dependent
No Charge
$40 Copay
40%*
Office Visits
Primary Office Visit
Specialist Office Visit
Chiropractic Visit
10%*
Urgent Care Services
Complex Imaging: MRI/CT/PET Scans
KIS Imaging
Any other locations
Inpatient Hospital Care
Facility Fee
Physician Fee
Outpatient Procedures
Emergency Services
Emergency Medical Transportation
$100 Copay
0%*
Mental Health/Chemical Dependency
Inpatient
Outpatient
Prescription Drug Coverage
Generic
Preferred Brand
Non-Preferred Brand
Specialty
Retail 30 Day Supply
$15 Copay
$30 Copay
$60 Copay
$90 Copay
Mail Order 90 Day Supply
Not Available
Telemedicine Services Through Teladoc
General Consultations
Dermatology
Therapist
Psychiatrist, initial evaluation
Psychiatrist, ongoing session
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 866-768-9686