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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

PPO 2

In-Network

Out-of-Network

Deductible

Individual

Family

 

$1,000

$2,000

 

$2,000

$4,000

Out-of-Pocket Maximum

Individual

Family

 

$6,000

$12,000

 

$12,000

$24,000

Preventive Care Services

No Charge

50% Coinsurance

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$50 Copay

25% Coinsurance

 

25%*

25%*

50%*

Urgent Care Services

$40 Copay

25%*

Complex Imaging: MRI/CT/PET Scans

$200 Copay

25%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

25%*

25%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

25%*

25%*

Emergency Room

Emergency Medical Transportation

$200 Copay

No Charge

$200 Copay

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$20 Copay

 

25%*

25%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay

$25 Copay

50% Coinsurance

$200 Copay

Mail Order 90 Day Supply

$20 Copay

$50 Copay

50% Coinsurance

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

PPO 3

In-Network

Out-of-Network

Deductible

Individual

Family

 

$1,500

$3,000

 

$3,000

$6,000

Out-of-Pocket Maximum

Individual

Family

 

$6,000

$12,000

 

$12,000

$24,000

Preventive Care Services

No Charge

50% Coinsurance

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$60 Copay

25% Coinsurance

 

25%*

25%*

50%*

Urgent Care Services

$40 Copay

25%*

Complex Imaging: MRI/CT/PET Scans

$300 Copay After Deductible

25%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

25%*

25%*

Outpatient Procedures

Facility Fee

Physician Fee

 

$500 Copay After Deductible

0%*

 

25%*

25%*

Emergency Room

Emergency Medical Transportation

$300 Copay After Deductible

No Charge

$300 Copay After Deductible

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$30 Copay

 

25%*

25%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay

$25 Copay

50% Coinsurance

$200 Copay

Mail Order 90 Day Supply

$20 Copay

$50 Copay

50% Coinsurance

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

PPO 6

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$7,000

$14,000

 

$15,000

$30,000

Preventive Care Services

No Charge

50% Coinsurance

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$75 Copay

25% Coinsurance

 

50%*

50%*

50%*

Urgent Care Services

$50 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

$300 Copay After Deductible

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

$750 Copay After Deductible

0%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

$300 Copay After Deductible

No Charge

$300 Copay After Deductible

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

$20 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay

$25 Copay

50% Coinsurance

$200 Copay

Mail Order 90 Day Supply

$20 Copay

$50 Copay

50% Coinsurance

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

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