Summary Of Medical Benefits
Copay Plan
In-Network
Out-Of-Network
Embedded Plan Year Deductible Employee Only Family |
$1,500 $3,000 |
Not Covered Not Covered |
Coinsurance |
20% |
Not Covered |
Embedded Out-Of-Pocket Maximum Employee Only Family |
$2,800 $5,600 |
Not Covered Not Covered |
Preventive Care |
100% Covered |
Not Covered |
Physician Services Specialist Services |
$25 Copay $50 Copay |
Not Covered Not Covered |
Hospital Services - Inpatient & Outpatient Care |
20%* |
Not Covered |
Emergency Services |
$300 Copay then 20%* |
Not Covered |
Urgent Care Services |
$50 Copay |
Not Covered |
Chiropractic Services Life Clinic Chiropractic Services |
$50 Copay $15 Copay |
Not Covered Not Covered |
Mental Health/Chemical Dependency Inpatient Outpatient |
20%* $50 Copay |
Not Covered Not Covered |
|
Retail 30 Day Supply |
Mail Order 90 Day Supply |
Prescription Drug Coverage Generic Preferred Brand Non-Preferred Brand Specialty |
$15 Copay $60 Copay $90 Copay 30% Coinsurance |
$45 Copay $180 Copay $270 Copay Not available |
NOTE: *After Deductible |
|
|
$2,300 HSA Plan
In-Network
Out-Of-Network
Non-Embedded Plan Year Deductible Employee Only Family |
$2,300 $3,700 |
Not Covered Not Covered |
Coinsurance |
0%* |
Not Covered |
Non-Embedded Out-Of-Pocket Maximum Employee Only Family |
$2,300 $3,700 |
Not Covered Not Covered |
Preventive Care |
100% covered |
No coverage |
Physician Services |
0%* |
Not Covered |
Hospital Services - Inpatient & Outpatient Care Outpatient Surgery |
0%* 0%* |
Not Covered Not Covered |
Emergency Services |
0%* |
Not Covered |
Urgent Care Services |
0%* |
Not Covered |
Chiropractic Services |
0%* |
Not Covered |
Mental health/Chemical Dependency |
0%* |
Not Covered |
|
Retail 30 Day Supply |
Mail Order 90 day Supply |
Prescription Drug Coverage Preventative Drugs per PBM List Generic Formulary Non-Formulary Specialty |
No Charge 0%* 0%* 0%* 0%* |
No Charge 0%* 0%* 0%* Not available |
*After Deductible |
|
|
$5,500 HSA Plan - Embedded
In-Network
Out-Of-Network
Plan Year Deductible Employee Only Family |
$5,500 $11,000 |
Not Covered Not Covered |
Coinsurance |
10%* |
Not Covered |
Out-Of-Pocket Maximum Employee Only Family |
$6,900 $13,800 |
Not Covered Not Covered |
Preventive Care |
100% covered |
Not Covered |
Physician Services |
10%* |
Not Covered |
Hospital Services - Inpatient & Outpatient Care Outpatient Surgery |
10%* 10%* |
Not Covered Not Covered |
Emergency Services |
10%* |
Not Covered |
Urgent Care Services |
10%* |
Not Covered |
Chiropractic Services |
10%* |
Not Covered |
Mental health/Chemical Dependency |
10%* |
Not Covered |
|
Retail 30 Day Supply |
Mail Order 90 day Supply |
Prescription Drug Coverage Preventative Drugs per PBM List Generic Formulary Non-Formulary Specialty |
No Charge 10%* 10%* 10%* 30%* |
No Charge 10%* 10%* 10%* Not available |
*After Deductible |
|
|
If you prefer talking with a HealthEZ representative, call 1-800-948-3253