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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

Premium Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$5,000

$10,000

 

$10,000

$20,000

Out-of-Pocket Maximum (Includes Medical Copays and Prescription Copays, does not include Deductible)

Individual

Family

 

$600

$1,200

 

$10,000

$20,000

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$50 Copay

20%*

 

50%*

50%*

50%*

Urgent Care Services

20%*

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room

Emergency Room – Facility Charges**

Emergency Room – Physician Charges**

Emergency Medical Transportation

 

$200 Copay, then 20%*

20%*

20%*

 

$200 Copay, then 20%*

20%*

50%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$50 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$30 Copay

$60 Copay

25% of Cost up to $75

Mail Order 90 Day Supply

$25 Copay

$75 Copay

$175 Copay

Not available

*Coinsurance after Deductible

**For a true emergency

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

 

 

Standard Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$9,450

$18,900

 

$20,000

$40,000

Out-of-Pocket Maximum

Individual

Family

 

$9,450

$18,900

 

$40,000

$80,000

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

50%*

50%*

50%*

Urgent Care Services

0%*

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$500 Copay, then 0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room

Emergency Room – Facility Charges**

Emergency Room – Physician Charges**

Emergency Medical Transportation

 

$750 Copay, then 0%*

0%*

0%*

 

$750 Copay, then 0%*

0%*

50%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

0%*

0%*

0%*

50%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not available

*Coinsurance after Deductible

**For a true emergency

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

 

 

If you prefer talking with a HealthEZ representative, call 888-592-6247