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