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

$4,000 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$4,000

$8,000

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

$8,000

$16,000

 

N/A

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay after Deductible

$40 Copay after Deductible

$40 Copay after Deductible

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$40 Copay after Deductible

Not Covered

Complex Imaging: MRI/CT/PET Scans

30%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

Not Covered

Not Covered

Emergency Room

Emergency Medical Transportation

$100 Copay after Deductible (Copay waived if admitted)

30%*

$100 Copay after Deductible (Copay waived if admitted)

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$40 Copay after Deductible

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

40%*

40%*

40%*

40%*

Mail Order 90 Day Supply

40%*

40%*

40%*

Not Covered

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 844-839-6744