Summary of Medical Benefits
Copay Plan 1
In-Network
Out-of-Network
|
Calendar Year Deductible Individual Family |
$2,000 $4,000 |
$10,000 $20,000 |
|
Out-of-Pocket Maximum Individual Family |
$8,000 $16,000 |
$20,000 $40,000 |
|
Preventative Services |
No Charge |
50%* |
|
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
$30 Copay $60 Copay $60 Copay |
50%* 50%* 50%* |
|
Urgent Care Services |
$75 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 Room Services Emergency Medical Transportation** |
$500 Copay 20%* |
50%* 20%* |
|
Mental Health/Chemical Dependency Inpatient Office Visit |
20%* $60 Copay |
50%* 50%* |
|
Teladoc Benefits General Consultations Dermatology Mental Health - Therapist Mental Health - Psychiatrist, Initial Evaluation Mental Health - Psychiatrist, Ongoing Session |
$10 Copay $10 Copay $10 Copay $10 Copay $10 Copay |
$10 Copay $10 Copay $10 Copay $10 Copay $10 Copay |
|
Prescription Drug Coverage Preventative Generic Preferred Brand Non-Preferred Brand Specialty Drugs |
Retail 30 Day Supply No Charge $15 Copay $40 Copay $100 Copay 20% Coinsurance |
Mail Order 90 Day Supply No Charge $30 Copay $80 Copay $200 Copay Not Available |
|
* Coinsurance after deductible |
|
|
|
** Covered as in-network in true-emergency Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions |
|
|
Copay Plan 2
In-Network
Out-of-Network
|
Calendar Year Deductible Individual Family |
$8,050 $16,100 |
$15,000 $30,000 |
|
Out-of-Pocket Maximum Individual Family |
$8,050 $16,100 |
$30,000 $60,000 |
|
Preventative Services |
No Charge |
50%* |
|
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
0%* 0%* 0%* |
50%* 50%* 50%* |
|
Urgent Care Services |
0%* |
50%* |
|
Complex Imaging: MRI/CT/PET Scans |
0%* |
50%* |
|
Inpatient Hospital Care Facility Fee Physician Fee |
0%* 0%* |
50%* 50%* |
|
Outpatient Procedures Facility Fee Physician Fee |
0%* 0%* |
50%* 50%* |
|
Emergency Room Services Emergency Medical Transportation** |
0%* 0%* |
50%* 50%* |
|
Mental Health/Chemical Dependency Inpatient Office Visit |
0%* 0%* |
50%* 50%* |
|
Teladoc Benefits General Consultations Dermatology Mental Health - Therapist Mental Health - Psychiatrist, Initial Evaluation Mental Health - Psychiatrist, Ongoing Session |
$10 Copay $10 Copay $10 Copay $10 Copay $10 Copay |
$10 Copay $10 Copay $10 Copay $10 Copay $10 Copay |
|
Prescription Drug Coverage Preventative Generic Preferred Brand Non-Preferred Brand Specialty |
Retail 30 Day Supply No Charge 0%* 0%* 0%* 0%* |
Mail Order 90 Day Supply No Charge 0%* 0%* 0%* Not Available |
|
* Coinsurance after deductible |
|
|
|
** Covered as in-network in true-emergency Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions |
|
|
HSA Plan 1
In-Network
Out-of-Network
|
Calendar Year Deductible Individual Family |
$3,500 $7,000 |
$15,000 $30,000 |
|
Out-of-Pocket Maximum Individual Family |
$6,000 $12,000 |
$25,000 $50,000 |
|
Preventative Services |
No Charge |
50%* |
|
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
30%* 30%* 30%* |
50%* 50%* 50%* |
|
Urgent Care Services |
30%* |
50%* |
|
Complex Imaging: MRI/CT/PET Scans |
30%* |
50%* |
|
Inpatient Hospital Care Facility Fee Physician Fee |
30%* 30%* |
50%* 50%* |
|
Outpatient Procedures Facility Fee Physician Fee |
30%* 30%* |
50%* 50%* |
|
Emergency Room Services Emergency Medical Transportation** |
30%* 30%* |
50%* 50%* |
|
Mental Health/Chemical Dependency Inpatient Office Visit |
30%* 30%* |
50%* 50%* |
|
Teladoc Benefits General Consultations Dermatology Mental Health - Therapist Mental Health - Psychiatrist, Initial Evaluation Mental Health - Psychiatrist, Ongoing Session |
$10 Copay $10 Copay $10 Copay $10 Copay $10 Copay |
$10 Copay $10 Copay $10 Copay $10 Copay $10 Copay |
|
Prescription Drug Coverage Preventative Generic Preferred Brand Non-Preferred Brand Specialty |
Retail 30 Day Supply No Charge 30%* 30%* 30%* 30%* |
Mail Order 90 Day Supply No Charge 30%* 30%* 30%* Not Available |
|
* 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 844-449-5544