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

Calendar Year Deductible

Employee Only

Family

 

$2,000

$4,000

 

$5,000

$10,000

Coinsurance

20%

50%

Out-Of-Pocket Maximum

Employee Only

Family

 

$5,000

$10,000

 

$10,000

$20,000

Preventive Care

100% Covered

50%*

Office Visits

Primary Services

Specialist Services

 

$10 Copay

$75 Copay

 

50%*

50%*

Hospital Services- Inpatient & Outpatient Care

20%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$500 Copay

20%*

 

50%*

50%*

Urgent Care Services

$50 Copay

50%*

Chiropractic Services

$75 Copay

50%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

20%*

$10 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

$75 Copay

$225 Copay

 

$30 Copay

$80 Copay

$150 Copay

Not Available

*After deductible

**Covered as in-network in true-emergency

 

 

 

 

 

 


If you prefer talking with a HealthEZ representative, call 844-281-5223