Plan Details

Summary of Medical Benefits

$1,500 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

$1,500

$3,000

$7,500

$15,000

Out-of-Pocket Maximum

Individual

Family

$7,150

$14,300

$15,000

$30,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$10 Copay

$40 Copay

$10 Copay

50%*

Urgent Care Services

$25 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

20%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

20%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

20%*

50%*

Emergency Room

Emergency Medical Transportation

$500 Copay, then 20%* (Copay waived if admitted)

20%*

$500 Copay, then 20%* (Copay waived if admitted)

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

20%*

$10 Copay

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$35 Copay

$60 Copay

$10/$35/$60 Copay

Mail Order 90 Day Supply

$25 Copay

$87.50 Copay

$150 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

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 844-281-5214

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