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.

Summary Of Medical Benefits

HSA Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$4,000

$8,000

 

$8,000

$16,000

Coinsurance

0%

50%

Out-Of-Pocket Maximum

Employee Only

Family

 

$5,500

$11,000

 

$11,000

$22,000

Preventive Care

100% Covered

50%*

Office Visits

Primary Services

Specialist Services

 

0%*

0%*

 

50%*

50%*

Hospital Services

0%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

0%*

0%*

 

50%*

50%*

Urgent Care Services

0%*

50%*

Chiropractic Services

0%*

50%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

0%*

0%*

 

50%*

50%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$15 Copay*

$50 Copay*

$70 Copay*

$350 Copay*

 

$30 Copay*

$100 Copay*

$140 Copay*

Not Available

*After deductible

 

 

**Covered as in-network in true-emergency

 

 


If you prefer talking with a HealthEZ representative, call 1-844-302-7790