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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 HDHP Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,300

$6,600

 

$6,600

$13,200

Out-of-Pocket Maximum

Individual

Family

 

$6,000

$12,000

 

$19,500

$39,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

25%*

25%*

25%*

 

50%*

50%*

50%*

Urgent Care Services

25%*

50%*

Complex Imaging: MRI/CT/PET Scans

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

25%*

25%*

25%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

25%*

25%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

25%*

25%*

25%*

Generic/Preferred Brand: 25%*; Non-Preferred Brand: 45%*

Mail Order 90 Day Supply

25%*

25%*

25%*

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$49 Copay

$79 Copay

$49 Copay

$49 Copay

$49 Copay

 

$49 Copay

$79 Copay

$49 Copay

$49 Copay

$49 Copay

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$2,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$6,000

 

$4,000

$12,000

Out-of-Pocket Maximum

Individual

Family

 

$6,600

$13,200

 

$9,900

$25,800

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$30 Copay

$30 Copay

 

40%*

40%*

40%*

Urgent Care Services

$30 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

20%*

20%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$30 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$8 Copay

$35 Copay

$75 Copay

Generic/Preferred Brand: 20%*; Non-Preferred Brand: 40%*

Mail Order 90 Day Supply

$16 Copay

$70 Copay

$150 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$15 Copay

$79 Copay

$15 Copay

$15 Copay

$15 Copay

 

$15 Copay

$79 Copay

$15 Copay

$15 Copay

$15 Copay

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$1,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$1,000

$3,000

 

$2,000

$6,000

Out-of-Pocket Maximum

Individual

Family

 

$4,200

$12,600

 

$8,700

$26,100

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$20 Copay

$20 Copay

 

40%*

40%*

40%*

Urgent Care Services

$20 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$20 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$8 Copay

$35 Copay

$75 Copay

Generic/Preferred Brand: 20%*; Non-Preferred Brand: 40%*

Mail Order 90 Day Supply

$16 Copay

$70 Copay

$150 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$5 Copay

$79 Copay

$5 Copay

$5 Copay

$5 Copay

 

$5 Copay

$79 Copay

$5 Copay

$5 Copay

$5 Copay

NOTE: * Coinsurance After Deductible

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

 

 

 

 

If you prefer talking with a HealthEZ representative, call 844-801-1909