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

$3,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,000

$6,000

 

$6,000

$12,000

Out-of-Pocket Maximum

Individual

Family

 

$6,000

$12,000

 

$10,000

$20,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$50 Copay

$50 Copay

 

50%*

50%*

50%*

Urgent Care Services

$75 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

$250 Copay After Deductible

20%*

$250 Copay After Deductible

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$20 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$15 Copay

$50 Copay

$125 Copay

20%*

Mail Order 90 Day Supply

$37.50 Copay

$125 Copay

$312.50 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatolology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Sessions

 

$0 Copay

$50 Copay

$0 Copay

$0 Copay

$0 Copay

 

$0 Copay

$50 Copay

$0 Copay

$0 Copay

$0 Copay

NOTE: * Coinsurance after deductible

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

 

 

 

 

$5,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$8,000

$16,000

 

$16,000

$32,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$75 Copay

$75 Copay

 

50%*

50%*

50%*

Urgent Care Services

$30 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

$300 Copay After Deductible

20%*

$300 Copay After Deductible

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$30 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$20 Copay

$60 Copay

$135 Copay

20%*

Mail Order 90 Day Supply

$50 Copay

$150 Copay

$337.50 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$0 Copay

$50 Copay

$0 Copay

$0 Copay

$0 Copay

 

$0 Copay

$50 Copay

$0 Copay

$0 Copay

$0 Copay

NOTE: * Coinsurance after deductible

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

 

 

 

 

$6,500 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$6,500

$13,000

 

$11,000

$22,000

Out-of-Pocket Maximum

Individual

Family

 

$8,500

$17,000

 

$16,000

$32,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$80 Copay

$80 Copay

 

50%*

50%*

50%*

Urgent Care Services

$50 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

Emergency Medical Transportation

30%*

30%*

30%*

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$40 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$20 Copay

30%*

30%*

30%*

Mail Order 90 Day Supply

$50 Copay

30%*

30%*

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$0 Copay

$50 Copay

$0 Copay

$0 Copay

$0 Copay

 

$0 Copay

$50 Copay

$0 Copay

$0 Copay

$0 Copay

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 877-496-0754