Plan Details

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

$1,000 Copay Plan

Reference Based Pricing

asd

Deductible

Individual

Family

 

$1,000

$2,000

 

$2,000

$4,000

Out-of-Pocket Maximum

Individual

Family

 

$2,000

$4,000

20

$4,000

$8,000

Preventative Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$40 Copay

$20 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 Services**

Emergency Room

Emergency Medical Transportation

 

$375 Copay

20%*

 

$375 Copay

20%*

Preventive Prescriptions

Generic

Preferred Brand

Non-Preferred Brand

Drugs over $350 and Specialty Drugs

 

$10 Copay

$35 Copay

$70 Copay

Not Covered

 

$10 Copay

$88 Copay

$175 Copay

Not Covered

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$20 Copay

 

50%*

50%*

Teledoc Services

General Consultations

Dermatology

Mental Health- Therapist

Mental Health- Psychiatrist, initial evaluation

Mental Health- Psychiatrist, ongoing session

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

NOTE: * Coinsurance After Deductible

 

 

If you prefer talking with a HealthEZ representative, call 888-592-6267