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

Calendar Year Deductible

Employee Only

Family

 

$1,000

$3,000

 

$2,000

$6,000

Coinsurance

30%

50%

Out-Of-Pocket Maximum

Employee Only

Family

 

$3,000

$9,000

 

$9,000

$18,000

Preventive Care

100% Covered

No Coverage

Physician Services

Primary

Specialist

Urgent Care

 

$35 Copay

$70 Copay

$100 Copay

 

50%*

50%*

50%*

Hospital Services- Inpatient & Outpatient Care

30%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$300 Copay

30%*

 

50%*

50%*

HealthiestYou Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist

Mental Health - Psychiatrist, ongoing session

 

100% Covered

$75 Copay

Not Covered

Not Covered

Not Covered

 

100% Covered

$75 Copay

Not Covered

Not Covered

Not Covered

Outpatient Therapy

Physical Therapy

Occupational & Speech Therapy

Chiropractic Services

 

$50 Copay

$70 Copay

$70 Copay

 

50%*

50%*

50%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

30%*

$70 Copay

 

50%*

50%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$15 Copay

$40 Copay

$70 Copay

20% Coinsurance

 

$37.50 Copay

$100 Copay

$175 Copay

Not Available

*After Deductible

 

 

**Covered as in-network in true emergency

 

 


If you prefer talking with a HealthEZ representative, call 888-592-6231