Plan Details

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

HSA Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$2,700

$5,400

 

$5,000

$10,000

Coinsurance

0%

50%

Out-Of-Pocket Maximum

Employee Only

Family

 

$2,700

$5,400

 

$5,000

$10,000

Preventive Care

100% Covered

50%*

Office Visits

Primary Services

Specialist Services

 

0%*

0%*

 

50%*

50%*

Hospital Services- Inpatient & Outpatient Care

0%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

0%*

0%*

 

50%*

50%*

Urgent Care Services

0%*

50%*

Chiropractic Services

0%*

50%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

0%*

0%*

 

50%*

50%*

Retail 30 Day Supply

Mail Order 90 day Supply

Prescription Drug Coverage

Generic

Formulary

Non-Formulary

Specialty

 

0%*

0%*

0%*

0%*

 

0%*

0%*

0%*

Not Available

*After deductible

**Covered as in-network in true-emergency

 

 

 

 

 

 

If you prefer talking with a HealthEZ representative, call 1-844-281-5215