Plan Details

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.

Questions about your benefits?

service@healthez.com

Register your myHealthEZ account

>>Click here


Summary of Medical Benefits

$1,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$1,000

$2,000

 

$2,000

$4,000

Out-of-Pocket Maximum

Individual

Family

 

$5,000

$10,000

 

$12,000

$24,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$75 Copay

$75 Copay*

 

50%*

50%*

50%*

Urgent Care Services

$75 Copay

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 Medical Transportation

$300 Copay, then 20% Coinsurance after Deductible

20%*

$300 Copay, then 20% Coinsurance after Deductible

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$25 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$3 Copay

$45 Copay

$75 Copay

20% Coinsurance up to $250

Mail Order 90 Day Supply

$6 Copay

$90 Copay

$150 Copay

Not Available

NOTE: * Coinsurance after deductible

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

 

 

 

 

$3,500 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,500

$7,000

 

$10,000

$30,000

Out-of-Pocket Maximum

Individual

Family

 

$3,500

$7,000

 

$20,000

$60,000

Preventive Care Services

No Charge

50%*

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

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

0%*

0%*

30%*

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Available

NOTE: * Coinsurance after deductible

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

 

 

 

 

$7,350 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$7,350

$14,700

 

$22,050

$66,150

Out-of-Pocket Maximum

Individual

Family

 

$9,100

$18,200

 

$42,050

$126,150

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$80 Copay

$80 Copay*

 

50%*

50%*

50%*

Urgent Care Services

$100 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$500 Copay*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

$250 Copay*

0%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

$500 Copay*

0%*

$500 Copay*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$500 Copay*

$40 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$3 Copay

$50 Copay

$80 Copay

20% Coinsurance up to $250

Mail Order 90 Day Supply

$6 Copay

$100 Copay

$160 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 844-302-7782