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

HDHP 1

In-Network

Out-of-Network

Calendar Year Accumulation

Non-Embedded Deductible

Employee only

Family

 

 

$1,500

$3,000

 

 

$2,500

$5,000

Coinsurance

0%

50%

Non-Embedded Out-of-Pocket Maximum

Employee only

Family

 

$3,000

$6,000

 

$7,500

$15,000

Recuro Telemedicine Services

100% Covered

100% Covered

Preventive Care

100% Covered

50% Coinsurance

Office Visits

Primary Services

Specialist Services

Walk In Clinics

Chiropractic Services

 

0%* After Deductible

0%* After Deductible

0%* After Deductible

0%* After Deductible

 

25%* After Deductible

25%* After Deductible

25%* After Deductible

25%* After Deductible

Urgent Care Services

0%* After Deductible

25%* After Deductible

Emergency Services

Emergency Room

Emergency Medical Transportation

 

0%* After Deductible

0%* After Deductible

 

0%* After Deductible

0%* After Deductible

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

 

0%* After Deductible

0%* After Deductible

 

25%* After Deductible

25%* After Deductible

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

 

0%* After Deductible

0%* After Deductible

0%* After Deductible

 

25%* After Deductible

25%* After Deductible

25%* After Deductible

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

0%* After Deductible

0%* After Deductible

 

25%* After Deductible

25%* After Deductible

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay after Deductible

$25 Copay after Deductible

$75 Copay after Deductible

$150 Copay after Deductible

Mail Order 90 Day Supply

$20 Copay after Deductible

$50 Copay after Deductible

$150 Copay after Deductible

Not Available

* Coinsurance

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

A Non-Embedded Deductible means that the family Deductible must be met before the Plan begins paying benefits that are subject to a Deductible

A Non-Embedded Out-of-Pocket maximum means that the family out-of-pocket maximum must be met before the Plan begins paying in full for all individuals

 

 

 

 

 

 

 

 

If you prefer talking with a HealthEZ representative, call 855-255-7060