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.

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Summary of Medical Benefits

PPO Plan

In-Network

Out-of-Network

Deductible

Individual

Individual under Family

Family

$2,500

$2,500

$5,000

$2,500

$2,500

$5,000

Out-of-Pocket Maximum

Individual

Individual under Family

Family

$2,500

$2,500

$5,000

$5,000

$5,000

$12,500

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

Urgent Care Services

0%*

0%*

0%*

0%*

40%*

40%*

40%*

40%*

Complex Imaging: MRI/CT/PET Scans

0%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

0%*

0%*

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

0%*

0%*

40%*

40%*

Emergency Room

Emergency Medical Transportation

No Charge

No Charge

No Charge

No Charge

Mental Health/Chemical Dependency

Inpatient

Office Visit

0%*

0%*

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$22 Copay

$66 Copay

$500 Copay

Mail Order 90 Day Supply

$20 Copay

$50 Copay

$150 Copay

Not Available

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 844-680-7800