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

Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Individual Under Family

Family

 

$300

$300

$900

 

$300

$300

$900

Out-Of-Pocket Maximum

Individual

Individual Under Family

Family

 

$600

$600

$1,800

 

$1,300

$1,300

$3,900

Preventive Care Services

Routine Eye Exam

One per 12 months

Frames and Lenses

$500 Maximum per Deductible Year

No Charge

 

​​$15 Copay​

 

No Charge

No Charge up to $500 per Deductible Year, then 40% Coinsurance After Deductible

 

​​$15 Copay​

 

No Charge

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$15 Copay

$15 Copay

$15 Copay

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Urgent Care Services

$15 Copay

40% Coinsurance After Deductible

Complex Imaging: MRI/CT/PET Scans

KIS Imaging

Non-KIS Imaging

 

No Charge

10% Coinsurance After Deductible

 

Not Covered

40% Coinsurance After Deductible

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10% Coinsurance After Deductible

10% Coinsurance After Deductible

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Outpatient Procedures

Facility Fee

Physician Fee

 

10% Coinsurance After Deductible

10% Coinsurance After Deductible

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Emergency Room

Emergency Medical Transportation

10% Coinsurance After Deductible

10% Coinsurance After Deductible

10% Coinsurance After Deductible

10% Coinsurance After Deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10% Coinsurance After Deductible

$15 Copay

 

40% Coinsurance After Deductible

40% Coinsurance After Deductible

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

 

$5 Copay

$8 Copay

$18 Copay

$5/$8/$18 Copay

 

$5 Copay

$8 Copay

$18 Copay

Not available

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

 

 

Dental Plan

Dental Plan

Deductible

Individual

Family

 

$50

$150

Maximums

Deductible Year Maximum Benefit Per Person Age 19 and Over

Deductible Year Maximum for Mouthguards

 

​​$3,000​

$600

Class I-Diagnostic and Preventive Procedures

No Charge

Class II-Basic Procedures

20% Coinsurance After Deductible

Class III – Major Procedures

20% Coinsurance After Deductible


If you prefer talking with a HealthEZ representative, call 844-804-8121