Plan Details

Not all coverage is the right coverage.

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

$0 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$0

$0

$0

 

$3,000

$3,000

$3,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$3,000

$3,000

$3,000

 

$10,000

$10,000

$10,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$20 Copay

$20 Copay

 

50%*

50%*

50%*

Urgent Care Services

$40 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

$300 Copay

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$300 Copay

No Charge

30%*

 

$300 Copay

No Charge

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$20 Copay

 

50%*

50%*

NOTE: * Coinsurance after deductible

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

 

 

 

 

$3,000 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$3,000

$3,000

$6,000

 

$7,500

$7,500

$15,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$8,000

$8,000

$16,000

 

$20,000

$20,000

$40,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$35 Copay

$35 Copay

$35 Copay

 

50%*

50%*

50%*

Urgent Care Services

$40 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

30%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$300 Copay

No Charge

30%*

 

$300 Copay

No Charge

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$35 Copay

 

50%*

50%*

NOTE: * Coinsurance after deductible

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

 

 

 

 

$2,500 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$2,500

$2,500

$5,000

 

$5,000

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$8,000

$8,000

$16,000

 

$20,000

$20,000

$40,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$30 Copay

$30 Copay

 

50%*

50%*

50%*

Urgent Care Services

$40 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

$300 Copay

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$300 Copay

No Charge

20%*

 

$300 Copay

No Charge

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$30 Copay

 

50%*

50%*

NOTE: * Coinsurance after deductible

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

 

 

 

 

$4,000 HSA Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$4,000

$4,000

$8,000

 

$10,000

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$4,000

$4,000

$8,000

 

$15,000

$15,000

$30,000

Preventive Care Services

No Charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

30%*

30%*

30%*

Urgent Care Services

0%*

30%*

Complex Imaging: MRI/CT/PET Scans

0%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

0%*

0%*

0%*

 

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

30%*

30%*

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 844-674-5354