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

HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Individual under Family

Family

$4,000

$4,000

$8,000

$8,000

$8,000

$16,000

Out-of-Pocket Maximum

Individual

Individual under Family Coverage

Family

$4,000

$4,000

$8,000

Unlimited

Unlimited

Unlimited

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

Urgent Care Services

0%*

0%*

0%*

0%*

50%*

50%*

50%*

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%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

0%*

0%*

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Medications > $350 and Specialty

Retail 30 Day Supply

0%*

0%*

0%*

Not Covered

Mail Order 90 Day Supply

0%*

0%*

0%*

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 844-855-0620