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
Copay Plan
In-Network
Out-of-Network
Deductible
Individual
Individual Under Family
Family
$300
$900
Out-Of-Pocket Maximum
$600
$1,800
$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 up to $500 per Deductible Year, then 40% Coinsurance After Deductible
Office Visits
Primary Office Visit
Specialist Office Visit
Chiropractic Visit
$15 Copay
40% Coinsurance After Deductible
Urgent Care Services
Complex Imaging: MRI/CT/PET Scans
KIS Imaging
Non-KIS Imaging
10% Coinsurance After Deductible
Not Covered
Inpatient Hospital Care
Facility Fee
Physician Fee
Outpatient Procedures
Emergency Room
Emergency Medical Transportation
Mental Health/Chemical Dependency
Inpatient
Office Visit
Prescription Drug Coverage
Generic
Preferred brand
Non-preferred brand
Specialty
$5 Copay
$8 Copay
$18 Copay
$5/$8/$18 Copay
Not available
*Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions
Dental Plan
$50
$150
Maximums
Deductible Year Maximum Benefit Per Person Age 19 and Over
Deductible Year Maximum for Mouthguards
$3,000
Class I-Diagnostic and Preventive Procedures
Class II-Basic Procedures
20% Coinsurance After Deductible
Class III – Major Procedures
If you prefer talking with a HealthEZ representative, call 844-804-8121