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Not all coverage is the right coverage.

The healthcare coverage you need is probably very different than the coverage some of your co-workers need. 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. That’s why HealthEZ provides multiple coverage options, so you’re never caught paying too much money, or worse, having too little coverage.

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Summary Of Medical Benefits

Copay Plan

In-Network

Out-Of-Network

Embedded Plan Year Deductible

Individual

Family

 

$1,500

$3,000

 

Not Covered

Not Covered

Embedded Out-Of-Pocket Maximum

Individual

Family

 

$2,800

$5,600

 

Not Covered

Not Covered

Preventive Care

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

Life Clinic Chiropractic Services

Urgent Care Services

 

$25 Copay

$50 Copay

$50 Copay

$15 Copay

$50 Copay

 

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Complex Imaging: MRI/CT/PET Scans

20%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

Not Covered

 

 

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

Not Covered

 

 

Emergency Room Services

Emergency Medical Transportation

$300 Copay, then 20%*

$300 Copay, then 20%*

Not Covered

Not Covered

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

20%*

$50 Copay

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$60 Copay

$90 Copay

30% Coinsurance

Mail Order 90 Day Supply

$45 Copay

$180 Copay

$270 Copay

Not available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$2,300 HSA Plan

In-Network

Out-Of-Network

Non-Embedded Plan Year Deductible

Individual

Family

 

$2,300

$3,700

 

Not Covered

Not Covered

Non-Embedded Out-Of-Pocket Maximum

Individual

Family

 

$2,300

$3,700

 

Not Covered

Not Covered

Preventive Care

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

Urgent Care Services

 

0%*

0%*

0%*

0%*

 

Not Covered

Not Covered

Not Covered

Not Covered

Complex Imaging: MRI/CT/PET Scans

0%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

Not Covered

 

 

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

Not Covered

 

 

Emergency Room Services

Emergency Medical Transportation

0%*

0%*

Not Covered

Not Covered

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

0%*

0%*

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$5,500 HSA Plan

In-Network

Out-Of-Network

Embedded Plan Year Deductible

Individual

Family

 

$5,500

$11,000

 

Not Covered

Not Covered

Embedded Out-Of-Pocket Maximum

Individual

Family

 

$6,900

$13,800

 

Not Covered

Not Covered

Preventive Care

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

Urgent Care Services

 

10%*

10%*

10%*

10%*

 

Not Covered

Not Covered

Not Covered

Not Covered

Complex Imaging: MRI/CT/PET Scans

10%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

Not Covered

 

 

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

Not Covered

 

 

Emergency Room Services

Emergency Medical Transportation

10%*

10%*

Not Covered

Not Covered

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

10%*

10%*

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

10%*

10%*

10%*

10%*

Mail Order 90 Day Supply

10%*

10%*

10%*

Not available

NOTE: * Coinsurance After Deductible

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

 

 

 

 


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