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.


Summary Of Medical Benefits

Copay Plan

In-Network

Out-Of-Network

Deductible

Individual

Individual under Family

Family

 

$1,250

$1,250

$3,750

 

$2,250

$2,250

$6,750

Out-Of-Pocket Maximum

Individual

Individual under Family

Family

 

$1,250

$1,250

$3,750

 

$4,250

$4,250

$12,750

Preventive Care Services

Employee

Dependent

 

No Charge

$40 Copay

 

40%*

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$40 Copay

10%*

 

40%*

40%*

40%*

Urgent Care Services

$40 Copay

40%*

Hospital Services Inpatient & Outpatient

10%*

40%*

Emergency Services

Emergency Medical Transportation

$100 Copay

0%*

$100 Copay

0%*

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

10%*

$40 Copay

 

40%*

40%*

Telemedicine Services Through Teladoc

General Consultations

Dermatology

Therapist

Psychiatrist, initial evaluation

Psychiatrist, ongoing session

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

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