Plan Details

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.

Questions about your benefits?

service@healthez.com

Register your myHealthEZ account

>>Click here


Summary of Medical Benefits

$2,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$4,000

 

$4,000

$8,000

Out-of-Pocket Maximum

Individual

Family

 

$8,150

$16,300

 

$16,300

$32,600

Preventive Care Services

No Charge

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$15 Copay

$100 Copay

$100 Copay

 

50%*

50%*

50%*

Urgent Care Services

$25 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

$300 Copay, then 20%*

20%*

$300 Copay, then 20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$15 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay

$35 Copay

$75 Copay

$250 Copay

Mail Order 90 Day Supply

$25 Copay

$88 Copay

$188 Copay

Not Available

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

NOTE: * Coinsurance after deductible

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

 

 

 

 

$5,000 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$5,000

$10,000

 

$14,000

$28,000

Preventive Care Services

No Charge

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

50%*

50%*

50%*

Urgent Care Services

0%*

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Available

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

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 844-281-5221