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.

Summary Of Medical Benefits

HSA Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Employee Only

Family

 

$5,000

$10,000

 

$10,000

$20,000

Coinsurance

0%

30%

Out-Of-Pocket Maximum

Employee Only

Family

 

$6,000

$12,000

 

$20,000

$40,000

Preventive Care

100% covered

30%*

Office Visits

Primary Services

Specialist Services

 

0%*

0%*

 

30%*

30%*

Hospital Services- Inpatient & Outpatient Care

0%*

30%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

0%*

0%*

 

30%*

30%*

Urgent Care Services

0%*

30%*

Chiropractic Services

0%*

30%*

Mental Health / Chemical Dependency

Inpatient

Outpatient

 

0%*

0%*

 

30%*

30%*

Retail 30 Day Supply

Mail Order 90 day Supply

Generic Prescription Deductible

Individual

Family

 

$1,500

$3,000

 

$1,500

$3,000

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

100% Covered after ^

$40 Copay*

$70 Copay*

$300 Copay*

 

100% Covered after ^

$80 Copay*

$140 Copay*

Not Available

^ Generic Prescription Deductible

*After medical deductible

** Covered as in-network in true-emergency

 

 

 

 

 

 

 

 

Contact your HR rep to choose your plan.

If you prefer talking with a HealthEZ representative, call 1-877-496-0754