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.

Summary Of Medical Benefits

PPO Copay Plan

In-Network

Out-Of-Network

Plan Year Deductible

Employee Only

Family

 

$1,000

$2,000

 

$3,000

$6,000

Coinsurance

20%

50%

Out-Of-Pocket Maximum

Employee Only

Family

 

$3,000

$6,000

 

$6,000

$12,000

Preventive Care

100% covered

Not covered

Physician Services

$20 copay

50%*

Hospital Services Inpatients & Outpatient Care

20%*

50%*

Emergency Services

$300 copay

$300 copay

Urgent Care Services

$30 copay

50%*

Chiropractic Services

$15 copay

Not covered

Mental health/Chemical Dependency

Inpatient

Outpatient

 

20%*

$20 copay

 

50%*

50%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Deductible (per person)

$50

$50

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$15 copay

$30 copay

$50 copay

20%*

 

$15 copay

$30 copay

$50 copay

Not Available

*After Deductible

 

 


If you prefer talking with a HealthEZ representative, call 1-855-290-1415