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

PPO 1

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$1,600

$3,200

 

$3,200

$6,400

Out-of-Pocket Maximum

Individual

Family

 

$1,600

$3,200

 

$5,000

$10,000

Preventive Care Services

No Charge

60%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

60%*

60%*

60%*

Urgent Care Services

0%*

60%*

Complex Imaging: MRI/CT/PET Scans

0%*

60%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

60%*

60%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

60%*

60%*

Emergency Services

Emergency Room

Emergency Medical Transportation

 

0%*

0%*

 

60%*

60%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

60%*

60%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

PPO 9

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

 

$3,000

$6,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$6,750

$13,500

 

$15,000

$30,000

Preventive Care Services

No Charge

50% Coinsurance

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$50 Copay

0%*

 

50%*

50%*

50%*

Urgent Care Services

$40 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 Services

Emergency Room

Emergency Medical Transportation

 

$300 Copay After Deductible

No Charge

 

$300 Copay After Deductible

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$20 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$25 Copay

50% Coinsurance

$200 Copay

Mail Order 90 Day Supply

$20 Copay

$50 Copay

50% Coinsurance

Not Available

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 855-255-7060