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

HDHP 4

In-Network

Out-of-Network

Embedded Deductible

Individual Coverage

Family Coverage

 

$5,000

$10,000

 

$10,000

$20,000

Embedded Out-of-Pocket Maximum

Individual Coverage

Family Coverage

 

$6,750

$13,500

 

$15,000

$30,000

Preventive Care Services

No Charge

50% Coinsurance

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

Urgent Care Services

20%*

20%*

20%*

20%*

50%*

50%*

50%*

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

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

20%*

20%*

 

50%*

50%*

Summary of Pharmacy Benefits

Prescription Drug Coverage

Expanded Preventive Generic

Expanded Preventive Preferred Brand

Generic

Preferred Brand

Non-Preferred Brand

Specialty

 

Retail 30 Day Supply

20% Coinsurance

20% Coinsurance

20%*

20%*

50%*

50%*

 

Mail Order 90 Day Supply

20% Coinsurance

20% Coinsurance

20%*

20%*

50%*

Not Available

Recuro Benefits

General Consultations

 

No Charge

 

No Charge

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

* After deductible

 

 

 

 

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