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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

$500 PPO Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$500

$1,000

 

$500

$1,000

Out-of-Pocket Maximum

Individual

Family

 

$1,500

$3,000

 

$3,000

$6,000

Preventive Care Services

No Charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$20 Copay

$20 Copay

 

30%*

30%*

30%*

Urgent Care Services

$20 Copay

30%*

Complex Imaging: MRI/CT/PET Scans

10%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

30%*

30%*

Emergency Room

Emergency Medical Transportation

$100 Copay, then 10%* (Copay waived if admitted)

10%*

$100 Copay, then 10%* (Copay waived if admitted)

10%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

$20 Copay

 

30%*

30%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$70 Copay

$110 Copay

$200 Copay

Mail Order 90 Day Supply

$37.50 Copay

$175 Copay

$275 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$1,000 PPO Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$1,000

$3,000

 

$1,000

$3,000

Out-of-Pocket Maximum

Individual

Family

 

$4,000

$8,000

 

$8,000

$16,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$30 Copay

$30 Copay

 

50%*

50%*

50%*

Urgent Care Services

$30 Copay

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

Emergency Medical Transportation

$100 Copay, then 20%* (Copay waived if admitted)

20%*

$100 Copay, then 20%* (Copay waived if admitted)

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$30 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$70 Copay

$110 Copay

$200 Copay

Mail Order 90 Day Supply

$37.50 Copay

$175 Copay

$275 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$3,000 PPO Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$3,000

$6,000

 

$3,000

$6,000

Out-of-Pocket Maximum

Individual

Family

 

$3,000

$6,000

 

$6,000

$12,000

Preventive Care Services

No Charge

20%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$40 Copay

$40 Copay

 

20%*

20%*

20%*

Urgent Care Services

$40 Copay

20%*

Complex Imaging: MRI/CT/PET Scans

0%*

20%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

20%*

20%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

20%*

20%*

Emergency Room

Emergency Medical Transportation

$100 Copay, then 0%* (Copay waived if admitted)

0%*

$100 Copay, then 0%* (Copay waived if admitted)

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$40 Copay

 

20%*

20%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$70 Copay

$110 Copay

$200 Copay

Mail Order 90 Day Supply

$37.50 Copay

$175 Copay

$275 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$5,000 PPO Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$6,500

$13,000

 

$13,000

$26,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$40 Copay

$40 Copay

 

40%*

40%*

40%*

Urgent Care Services

$40 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

$100 Copay, then 20%* (Copay waived if admitted)

20%*

$100 Copay, then 20%* (Copay waived if admitted)

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$40 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$15 Copay

$70 Copay

$110 Copay

$200 Copay

Mail Order 90 Day Supply

$37.50

$175 Copay

$275 Copay

Not Covered

NOTE: * Coinsurance After Deductible

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

 

 

 

 

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