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

Non-Embedded Deductible

Individual

Family

 

$1,650

$3,300

 

$3,000

$6,000

Embedded Out-of-Pocket Maximum

Individual

Family

 

$3,300

$6,600

 

$8,000

$16,000

Preventive Care

No Charge

50% Coinsurance

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

25%*

25%*

25%*

Urgent Care Services

0%*

25%*

Complex Imaging: MRI/CT/PET Scans

0%*

25%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

25%*

25%*

Outpatient Porcedures

Facility Fee

Physician Fee

 

0%*

0%*

 

25%*

25%*

Emergency Services

Emergency Room

Emergency Medical Transportation

 

0%*

0%*

 

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office VIsit

 

0%*

0%*

 

25%*

25%*

Prescription Drug Coverage

Expanded Preventive Generic

Expanded Preventive Preferred brand

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$25 Copay

$10 Copay After Deductible

$25 Copay After Deductible

50%*

$150 Copay After Deductible

Mail Order 90 Day Supply

$20 Copay

$50 Copay

$20 Copay After Deductilbe

$50 Copay After Deductible

50%*

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 855-255-7060