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.

Questions about your benefits?

service@healthez.com

Register your myHealthEZ account

>>Click here


Summary of Medical Benefits

$6,350 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$6,350

$6,350

$12,700

 

$10,000

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$7,900

$7,900

$15,800

 

$23,700

$23,700

$47,400

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$80 Copay

$80 Copay

 

40%*

40%*

40%*

Urgent Care Services

$100 Copay

$100 Copay

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$500 Copay, then 20% Coinsurance

20%*

20%*

 

$500 Copay, then 20% Coinsurance

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$80 Copay

 

40%*

40%*

Prescription Drug Coverage

Preventive

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

No Charge

$20 Copay

$50 Copay

$90 Copay

25%*

Mail Order 90 Day Supply

No Charge

$60 Copay

$150 Copay

$270 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$8,700 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$8,700

$8,700

$17,400

 

$10,000

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$8,700

$8,700

$17,400

 

$17,400

$17,400

$34,800

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

0%*

0%*

 

50%*

50%*

50%*

Urgent Care Services

0%*

0%*

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

Facility Fee

Physician Fee

Emergency Medical Transportation

 

0%*

0%*

0%*

 

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Prescription Drug Coverage

Preventive

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

No Charge

$30 Copay

$60 Copay

$90 Copay

0%*

Mail Order 90 Day Supply

No Charge

$90 Copay

$180 Copay

$270 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$3,500 Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$3,500

$3,500

$10,500

 

$10,000

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$7,900

$7,900

$15,800

 

$23,700

$23,700

$47,400

Preventive Care Services

No Charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$60 Copay

0%*

 

30%*

30%*

30%*

Urgent Care Services

$75 Copay

$75 Copay

Complex Imaging: MRI/CT/PET Scans

0%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$350 Copay

No Charge

0%*

 

$350 Copay

No Charge

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$60 Copay

 

30%*

30%*

Prescription Drug Coverage

Preventive

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

No Charge

$15 Copay

$45 Copay

$85 Copay

25% Coinsurance up to $350

Mail Order 90 Day Supply

No Charge

$45 Copay

$135 Copay

$255 Copay

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 844-676-9343