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

Copay 1 Plan

In-Network

Out-of-Network

Embedded Deductible

Individual

Individual under Family Coverage

Family

 

$5,000

$5,000

$10,000

 

$15,000

$15,000

$30,000

Embedded Out-of-Pocket Maximum

Individual

Individual under Family Coverage

Family

 

$8,500

$8,500

$17,000

 

$25,500

$25,500

$51,000

Preventative Services

No Charge

50% Coinsurance*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$60 Copay

$30 Copay

 

50% Coinsurance*

50% Coinsurance*

50% Coinsurance*

Urgent Care Services

$30 Copay

50% Coinsurance*

Complex Imaging: MRI/CT/PET Scans

20% Coinsurance*

50% Coinsurance*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20% Coinsurance*

20% Coinsurance*

 

50% Coinsurance*

50% Coinsurance*

Outpatient Procedures

Facility Fee

Physician Fee

 

20% Coinsurance*

20% Coinsurance*

 

50% Coinsurance*

50% Coinsurance*

Emergency Room Services**

Emergency Medical Transportation**

$500 Copay

$500 Copay per trip then 20% Coinsurance*

$300 Copay*

0% Coinsurance*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20% Coinsurance*

$30 Copay

 

50% Coinsurance*

50% Coinsurance*

Recuro Benefits

General Consultations

 

No Charge

 

No Charge

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$35 Copay

$70 Copay

$210 Copay

Mail Order 90 Day Supply

$25 Copay

$105 Copay

$210 Copay

$630 Copay

*After Deductible

 

 

If you prefer talking with a HealthEZ representative, call 855-255-7060