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.

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Summary of Medical Benefits

$2.500 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,500

$5,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$5,000

$10,000

 

$10,000

$20,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay after Deductible

$75 Copay after Deductible

$25 Copay after Deductible

 

50%*

50%*

50%*

Urgent Care Services

$50 Copay after Deductible

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%* (copay waived if admitted)

20%*

$300 Copay then 20%* (copay waived if admitted)

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$75 Copay after Deductible

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay after Deductible

$35 Copay after Deductible

$70 Copay after Deductible

$500 Copay after Deductible

Mail Order 90 Day Supply

$25 Copay after Deductible

$87.50 Copay after Deductible

$175 Copay after Deductible

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapy

Mental Health - Psychiatry, Initial Evaluation

Mental Health - Psychiatry, Ongoing Session

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

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 855-280-9637