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
In-Network
Out-of-Network
Calendar Year Deductible
Individual
Individual Under Family
Family
$0
$500
$1,000
Out-of-Pocket Maximum
Individual under Family
$2,500
$6,000
Preventative Care Services
No Charge
30%*
Office Visit
Primary Office Visit
Specialist Office Visit
Chiropractic Visit
$20 Copay
$20
Urgent Care Services
$25 Copay
Complex Imaging: MRI/CT/PET Scans
$100 Copay per Scan
$100 Copay per Scan, then 30%*
Inpatient Hospital Services
Facility Charges
Physician Charges
$200 Copay
$200 Copay, then 30%*
Outpatient Procedures
$100 Copay
$100 Copay, then 30%*
Emergency Room Services
Emergency Medical Transportation
$50 Copay
Mental Health/Chemical Dependency
Inpatient
* Coinsurance After Deductible
Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions
Dental Plan
Deductible
$50
$150
Deductible Year Maximum Benefit Per Person (Excluding Orthodontia)
Lifetime Maximum Benefit for Orthodontia (Coverage for participants up to age 19)
$2,500
Class I-Diagnostic and Preventive Procedures
Class II-Basic Procedures
10% Coinsurance After Deductible
Class III – Major Procedures
40% Coinsurance After Deductible
Class IV - Orthodontia
50% Coinsurance After Deductible
If you prefer talking with a HealthEZ representative, call 888-588-6521