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
Deductible
Individual
Family
$1,000
$2,000
Out-of-Pocket Maximum
$4,000
Preventative Care
No Charge
Office Visits
Primary Office Visit
Specialist Office Visit
Chiropractic Visit
$20 Copay
$40 Copay
Urgent Care Services
$75 Copay
Complex Imaging: MRI/CT/PET Scans
20%*
Inpatient Hospital Care
Facility Fee
Physician Fee
Outpatient Procedures
Emergency Services**
Emergency Room
Emergency Medical Transportation
$375 Copay
Mental Health/Chemical Dependency
Inpatient
Office Visit
Teledoc Services
General Consultations
Dermatology
Mental Health- Therapist
Mental Health- Psychiatrist, initial evaluation
Mental Health- Psychiatrist, ongoing session
NOTE: * Coinsurance 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
If you prefer talking with a HealthEZ representative, call 888-592-6267