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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

HSA Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$3,400

$3,400

$6,400

 

$6,000

$6,000

$12,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$4,000

$4,000

$8,000

 

$8,000

$8,000

$16,000

Preventative Services

No Charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

30%*

30%*

30%*

Urgent Care Services

0%*

30%*

Complex Imaging: MRI/CT/PET Scans

0%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Emergency Room Services **

Emergency Medical Transportation **

0%*

0%*

30%*

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

30%*

30%*

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

10%*

10%*

10%*

10%*

Mail Order 90 Day Supply

10%*

10%*

10%*

Not Available

* Coinsurance after deductible

 

 

** Covered as in-network in true-emergency

 

 

If you prefer talking with a HealthEZ representative, call 844-302-7776