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.

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Summary of Medical Benefits

Minimum Essential Coverage Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

N/A

N/A

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

N/A

N/A

 

N/A

N/A

Preventive Care Services

No Charge

No Coverage

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

No Coverage

No Coverage

No Coverage

 

No Coverage

No Coverage

No Coverage

Urgent Care Services

No Coverage

No Coverage

Complex Imaging: MRI/CT/PET Scans

No Coverage

No Coverage

Hospital Services Inpatient & Outpatient

No Coverage

No Coverage

Emergency Room Services

Emergency Medical Transportation

No Coverage

No Coverage

No Coverage

No Coverage

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

No Coverage

No Coverage

 

No Coverage

No Coverage

Prescription Drug Coverage

Preventive

Non-Preventive Generic

Non-Preventive Preferred brand

Non-Preventive Non-preferred brand

Non-Preventive Specialty

Retail 30 Day Supply

No Charge

No Coverage

No Coverage

No Coverage

No Coverage

Mail Order 90 Day Supply

No Charge

No Coverage

No Coverage

No Coverage

No Coverage

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

 

 

If you prefer talking with a HealthEZ representative, call 844-302-7774