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.

Summary Of Medical Benefits

HSA Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Individual

Individual Under Family Coverage

Family

 

$2,000

$3,200

$4,000

 

$4,000

$4,000

$8,000

Coinsurance

20%

40%

Out-Of-Pocket Maximum

Employee Only

Individual Under Family Coverage

Family

 

$4,000

$4,000

$8,000

 

$8,000

$8,000

$16,000

Preventive Care

100% Covered

40%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

20%*

20%*

20%*

 

40%*

40%*

20%*

Hospital Services

20%*

40%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

20%*

20%*

 

40%*

40%*

Urgent Care Services

20%*

40%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

20%*

20%*

 

40%*

40%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$15 Copay*

$30 Copay*

$60 Copay*

20%*

 

$45 Copay*

$90 Copay*

$180 Copay*

Not Available

* After deductible

 

 

** True emergencies covered at in-network level

 

 


If you prefer talking with a HealthEZ representative, call 1-888-454-5270