Plan Details

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 1

In-Network

Out-of-Network

Calendar Year Accumulation

Embedded Deductible

Employee only

Family

 

 

$250

$500

 

 

$750

$1,500

Coinsurance

20%

50%

Embedded Out-of-Pocket Maximum

Employee only

Family

 

$2,000

$4,000

 

$6,000

$12,000

Recuro Telemedicne Services

100% Covered

100% Covered

Preventive Care

100% Covered

50%*

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

$20 Copay

$35 Copay

$35 Copay

 

50%*

50%*

50%*

Urgent Care Services

$100 Copay

50%*

Emergency Services

Emergency Room

Emergency Medical Transportation

 

$350 Copay (Copay Waived if Admitted)

20%

 

$350 Copay (Copay Waived if Admitted)

20%*

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

 

20%*

20%*

 

50%*

50%*

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

 

No Charge

No Charge

20%*

 

50%*

50%*

50%*

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

20%*

$20 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$30 Copay

$50 Copay

25%

Mail Order 90 Day Supply

$25 Copay

$75 Copay

$125 Copay

Not Available

*After Deductible

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

An Embedded Deductible means that each individual will only have to meet the individual Deductible before the Plan begins paying benefits for such individual that are subject to a Deductible

An Embedded Out-of-Pocket Maximum means that each individual will only have to meet the individual out-of-pocket maximum before the Plan begins paying in full for such individual.

 

 

 

 

 

 

 

 

If you prefer talking with a HealthEZ representative, call 855-255-7060