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Not all coverage is the right coverage.

The healthcare coverage you need is probably very different than the coverage some of your co-workers need. 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. That’s why HealthEZ provides multiple coverage options, so you’re never caught paying too much money, or worse, having too little coverage.

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Summary of Medical Benefits

$3,300 HSA 1 Plan

Reference Based Pricing

Deductible

Individual

Family

 

$3,300

$6,600

Out-of-Pocket Maximum

Individual

Family

 

$5,500

$11,000

Preventive Care Services

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

10%*

10%*

10%*

Urgent Care Services

10%*

Complex Imaging: MRI/CT/PET Scans

10%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

Emergency Room

Emergency Medical Transportation

10%*

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

10%*

Telemedicine Services Through Teladoc

General Consultations

Dermatology

 

10%*

10%*

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

Summary of Pharmacy Benefits

Retail 30 Day Supply

Mail Order 90 Day Supply

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

 

$10 Copay After Deductible

$35 Copay After Deductible

$70 Copay After Deductible

$70 Copay After Deductible

 

$25 Copay After Deductible

$88 Copay After Deductible

$175 Copay After Deductible

Not Covered

$2,500 Copay 1 Plan

Reference Based Pricing

Deductible

Individual

Family

 

$2,500

$5,000

Out-of-Pocket Maximum

Individual

Family

 

$6,350

$12,700

Preventive Care Services

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$60 Copay

$60 Copay

Urgent Care Services

$60 Copay

Complex Imaging: MRI/CT/PET Scans

20%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$400 Copay

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$60 Copay

Telemedicine Services Through Teladoc

General Consultations

Dermatology

 

$25 Copay

$65 Copay

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

Summary of Pharmacy Benefits

Retail 30 Day Supply

Mail Order 90 Day Supply

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

 

$10 Copay

$45 Copay

$95 Copay

$95 Copay

 

$25 Copay

$113 Copay

$238 Copay

Not Covered

$6,000 Plus Copay 2 Plan

Reference Based Pricing

Deductible

Individual

Family

 

$6,000

$12,000

Out-of-Pocket Maximum

Individual

Family

 

$8,150

$16,300

Preventive Care Services

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$75 Copay

$75 Copay

Urgent Care Services

$75 Copay

Complex Imaging: MRI/CT/PET Scans

10%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$450 Copay

10%*

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

$75 Copay

Telemedicine Services Through Teladoc

General Consultations

Dermatology

 

$25 Copay

$75 Copay

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

Summary of Pharmacy Benefits

Retail 30 Day Supply

Mail Order 90 Day Supply

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

 

$10 Copay

$45 Copay

$95 Copay

$95 Copay

 

$25 Copay

$113 Copay

$238 Copay

Not Available

$6,000 Copay 3 Plan

Reference Based Pricing

Deductible

Individual

Family

 

$6,000

$12,000

Out-of-Pocket Maximum

Individual

Family

 

$8,550

$17,100

Preventive Care Services

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

No Charge

$100 Copay

$100 Copay

Urgent Care Services

No Charge

Complex Imaging: MRI/CT/PET Scans

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

Emergency Room

Facility Fee

Physician Fee

Emergency Medical Transportation

 

$500 Copay

30%*

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$100 Copay

Telemedicine Services Through Teladoc

General Consultations

Dermatology

 

$0 Copay

$85 Copay

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

Summary of Pharmacy Benefits

Retail 30 Day Supply

Mail Order 90 Day Supply

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

 

$10 Copay

$65 Copay

$125 Copay

$250 Copay

 

$25 Copay

$163 Copay

$313 Copay

Not Covered

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