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

Reference Based Pricing Plan

In-Network

Out-Of-Network

Plan Year Deductible

Employee Only

Family

 

$3,000

$6,000

 

N/A

N/A

Coinsurance

20%

N/A

Out-Of-Pocket Maximum

Employee Only

Family

 

$6,600

$13,200

 

N/A

N/A

Preventive Care

100% Covered

N/A

Office Visits

Primary Services

Specialist Services

 

$40 Copay

$60 Copay

 

N/A

N/A

Hospital Services

20%*

N/A

Emergency Services

Emergency Room

Emergency Medical Transportation

 

20%*

20%*

 

N/A

N/A

Urgent Care Services

$75 Copay

N/A

Chiropractic Services

$60 Copay

N/A

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

20%*

$60 Copay

 

N/A

N/A

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

No Charge

$50 Copay

$75 Copay

20%

 

No Charge

$100 Copay

$150 Copay

Not Available

* After deductible

 

 


If you prefer talking with a HealthEZ representative, call 1-844-204-3766