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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Plan Details

PPO 4

In-Network

Out of Network

Deductible

Individual Coverage

Family Coverage

 

$2,000

$4,000

 

$4,000

$8,000

Out-of-Pocket Maximum

Individual Coverage

Family Coverage

 

$6,000

$12,000

 

$12,000

$24,000

Preventive Care Services

No Charge

50% Coinsurance

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

No Charge

$20 Copay

$75 Copay

25%*

 

50%*

50%*

50%*

Urgent Care Services

$50 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

$300 Copay after Deductible

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

$750 Copay after Deductible

0%*

 

50%*

50%*

Emergency Services

Emergency Room Services**

Emergency Medical Transportation**

 

$300 Copay after deductible

0%*

 

$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

** Covered as in-network in true-emergency

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