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

Copay Plan

Tier 1 In-Network

Tier 2 In-Network

Out of Network

Embedded Deductible

Individual Coverage

Individual under Family Coverage

Family Coverage

 

$500

$500

$1,000

 

$1,500

$1,500

$3,000

 

$4,000

$4,000

$8,000

Embedded Out-of-Pocket Maximum

Individual Coverage

Individual under Family Coverage

Family Coverage

 

$2,500

$2,500

$5,000

 

$3,500

$3,500

$7,000

 

$6,000

$6,000

$12,000

Preventive Care Services

No Charge

No Charge

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$10 Copay

$20 Copay

Not Available

 

$30 Copay

$60 Copay

20%*

 

50%*

50%*

50%*

Urgent Care Services

$25 Copay

$75 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

20%*

20%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

$300 Copay, then 20%*

20%*

$300 Copay, then 20%*

20%*

50%*

50%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$60 Copay

 

20%*

$60 Copay

 

50%*

50%*

If you prefer talking with a HealthEZ representative, call 1-844-671-4963