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
Copay Plan
In-Network
Out-of-Network
Deductible
Individual
Family
$2,500
$5,000
$10,000
Out-of-Pocket Maximum
$20,000
Preventive Care Services
No Charge
50%* After Deductible
Office Visits
Primary Office Visit
Specialist Office Visit
Chiropractic Visit
$25 Copay
20%* After Deductible
Urgent Care Services
$75 Copay
Complex Imaging: MRI/CT/PET Scans
Inpatient Hospital Care
Facility Fee
Physician Fee
$200 Copay, then 20%* After Deductible
$300 Copay, then 50%* After Deductible
Outpatient Procedures
$150 Copay, then 20%* After Deductible
$250 Copay, then 50%* After Deductible
Emergency Room
Emergency Medical Transportation
$400 Copay, then 20%* After Deductible
Mental Health/Chemical Dependency
Inpatient
Office Visit
Prescription Drug Coverage
Generic
Preferred Brand
Non-Preferred Brand
Specialty Drugs
Retail 30 Day Supply
$5 Copay
$45 Copay
$85 Copay
$250 Copay
Mail Order 90 Day Supply
$15 Copay
$135 Copay
$225 Copay
Not Available
NOTE: * Coinsurance
Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions
If you prefer talking with a HealthEZ representative, call 888-806-3169