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Not all coverage is the right coverage.

The healthcare coverage you need is probably very different than the coverage some of your co-workers need. 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. That’s why HealthEZ provides multiple coverage options, so you’re never caught paying too much money, or worse, having too little coverage.

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Summary of Medical Benefits

HSA 1 Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$1,875

$3,750

 

$2,000

$4,000

Out-of-Pocket Maximum

Individual

Family

 

$3,800

$6,600

 

$5,250

$10,500

Preventative Services

No Charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay*

$40 Copay*

$40 Copay*

 

30%*

30%*

30%*

Urgent Care Services

$40 Copay*

30%*

Complex Imaging: MRI/CT/PET Scans

10%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

30%*

30%*

Emergency Room Services

Emergency Medical Transportation

$100 Copay*

10%*

$100 Copay*

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

$25 Copay*

 

30%*

30%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay*

$30 Copay*

$75 Copay*

20%* up to $200

Mail Order 90 Day Supply

$30 Copay*

$60 Copay*

$150 Copay*

Not Available

NOTE: * Coinsurance or Copay After Deductible

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

 

 

 

 

Copay 1 Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$1,000

$2,000

 

$2,500

$5,000

Out-of-Pocket Maximum

Individual

Family

 

$5,000

$10,000

 

$7,000

$14,000

Preventative Services

No Charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$40 Copay

$40 Copay

 

30%*

30%*

30%*

Urgent Care Services

$40 Copay

30%*

Complex Imaging: MRI/CT/PET Scans

20%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

30%*

30%*

Emergency Room Services

Emergency Medical Transportation

$100 Copay

20%*

$100 Copay

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$25 Copay

 

30%*

30%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay*

$30 Copay*

$75 Copay*

20%* up to $200

Mail Order 90 Day Supply

$30 Copay*

$60 Copay*

$150 Copay*

Not Available

NOTE: * Coinsurance or Copay After Deductible

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

 

 

 

 

Copay 2 Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$1,000

$2,000

 

N/A

N/A

Non-Embedded Out-of-Pocket Maximum

Individual

Family

 

$4,500

$9,000

 

N/A

N/A

Preventative Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$40 Copay

$40 Copay

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$40 Copay

Not Covered

Complex Imaging: MRI/CT/PET Scans

20%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

Not Covered

Not Covered

Emergency Room Services

Emergency Medical Transportation

$100 Copay

20%*

$100 Copay

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$25 Copay

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay*

$30 Copay*

$75 Copay*

20%* up to $200

Mail Order 90 Day Supply

$30 Copay*

$60 Copay*

$150 Copay*

Not Available

NOTE * Coinsurance or Copay After Deductible

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

 

 

 

 

If you prefer talking with a HealthEZ representative, call 844-281-5219