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

$3,300 HDHP

In-Network

Out-Of-Network

Calendar Year Deductible

Individual

Individual under Family

Family

 

$3,300

$3,300

$6,600

 

$13,100

$13,100

$26,100

Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$5,000

$5,000

$10,000

 

$18,100

$18,100

$36,200

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

50%*

50%*

50%*

Urgent Care Services

0%*

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

0%*

0%*

0%*

50%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Prescription Drug Coverage

Preventive

Expanded Preventive - Gerneric

Expanded Preventive - Preferred Brand

Generic

Preferred Brand

Non-Preferred Brand

Retail 30 Day Supply

No Charge

No Charge

No Charge

$10 Copay After Deductible

$25 Copay After Deductible

$75 Copay After Deductible

Mail Order 90 Day Supply

No Charge

No Charge

No Charge

$20 Copay After Deductible

$50 Copay After Deductible

$150 Copay After Deductible

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