Plan Details

Summary Of Medical Benefits

Copay Plan

In-Network

Out-Of-Network

Deductible

Individual

Family

$500

$1,500

$1,000

$3,000

Out-Of-Pocket Maximum

Individual

Family

$3,500

$7,000

$14,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$25 copay

$50 Copay

20%*

50%*

Urgent Care Services

$50 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

20%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

20%*

50%*

Emergency Services

Emergency Room

Emergency Medical Transportation

$150 copay

$200 Copay

$150 copay

$200 Copay

Mental health/Chemical Dependency

Inpatient

Office Visit

20%*

$50 Copay

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$15 copay

$40 copay

$60 copay

30% Coinsurance up to $250

Mail Order 90 Day Supply

$15 copay

$80 copay

$120 copay

Not Available

Healthiest You Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

No Charge

$75 Copay

No Charge

$75 Copay

No Charge

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 1-844-801-1907

Questions about your benefits?

Register your myHealthEZ account