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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.

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Summary of Medical Benefits

$500 Copay Plan Schedule of Benefits

In-Network

Out-of-Network

Deductible

Individual

Individual Under Family

Family

 

$500

$500

$1,000

 

$2,500

$2,500

$5,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$2,500

$2,500

$5,000

 

$4,500

$4,500

$9,000

Preventive Care Services

No Charge

40% Coinsurance After Deductible

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$15 Copay

$25 Copay

$25 Copay

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Urgent Care Services

$25 Copay

40% Coinsurance After Deductible

Complex Imaging: MRI/CT/PET Scans

20% Coinsurance After Deductible

40% Coinsurance After Deductible

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20% Coinsurance After Deductible

20% Coinsurance After Deductible

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Outpatient Procedures

Facility Fee

Physician Fee

 

20% Coinsurance After Deductible

20% Coinsurance After Deductible

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Emergency Room

Emergency Medical Transportation

$100 Copay

20% Coinsurance After Deductible

$100 Copay

20% Coinsurance After Deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20% Coinsurance After Deductible

$25 Copay

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$20 Copay

$40 Copay

$70 Copay

$20/$40/$70 Copay

 

$40 Copay

$80 Copay

$140 Copay

Not available

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

 

 

$2,000 Copay Plan Schedule of Benefits

In-Network

Out-of-Network

Deductible

Individual

Individual Under Family

Family

 

$2,000

$2,000

$4,000

 

$2,500

$2,500

$5,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$4,500

$4,500

$9,000

 

$6,650

$6,650

$13,300

Preventive Care Services

No Charge

40% Coinsurance After Deductible

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$40 Copay

$40 Copay

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Urgent Care Services

$40bCopay

40% Coinsurance After Deductible

Complex Imaging: MRI/CT/PET Scans

20% Coinsurance After Deductible

40% Coinsurance After Deductible

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20% Coinsurance After Deductible

20% Coinsurance After Deductible

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Outpatient Procedures

Facility Fee

Physician Fee

 

20% Coinsurance After Deductible

20% Coinsurance After Deductible

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Emergency Room

Emergency Medical Transportation

$100 Copay

20% Coinsurance After Deductible

$100 Copay

20% Coinsurance After Deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20% Coinsurance After Deductible

$40 Copay

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$20 Copay

$40 Copay

$70 Copay

$20/$40/$70 Copay

 

$40 Copay

$80 Copay

$140 Copay

Not available

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

 

 

If you prefer talking with a HealthEZ representative, call 866-746-4059