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
Reference Based Pricing Plan 1
Reference Based Pricing
Calendar Year Deductible
Individual Only
Individual Under Family
Family
$1,000
$2,000
Coinsurance
20%
Out-of-Pocket Maximum
$4,000
Preventative Care
100% Covered
Office Visits
Primary Services
Specialist Office Visit
Chiropractic Services
$20 Copay
$40 Copay
Hospital Services
20%*
Emergency Services**
Emergency Room
Emergency Medical Transportation
$375 Copay
Urgent Care Services
$75 Copay
Teledoc Services
General Consultations
Dermatology
Mental Health- Therapist
Mental Health- Psychiatrist, initial evaluation
Mental Health- Psychiatrist, ongoing session
No Charge
Mental Health/ Chemical Dependency
Inpatient
Outpatient
*After Deductible
** Referenced Based Pricing applies unless a network is utilized
Note: Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions
Summary of Pharmacy Benefits
Retail 30 Day Supply
Mail Order 90 Day Supply
Prescription Drug Coverage
Generic
Preferred Brand
Non-preferred Brand
Specialty
$10 Copay
$35 Copay
$70 Copay
Not Covered
$88 Copay
$175 Copay
Not available
If you prefer talking with a HealthEZ representative, call 888-592-6267