Compare Plans

Not all coverage is the right coverage.

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

$1,250 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$1,250

$2,500

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$3,000

$6,000

 

$15,000

$30,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$40 Copay

$20 Copay

 

40%*

40%*

40%*

Urgent Care Services

$50 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

$0 Copay After Deductible

$500 Copay After Deductible, then 40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$0 Copay After Deductible

$0 Copay After Deductible

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

0%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

$500 Copay After Deductible

30%*

$500 Copay After Deductible

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$0 Copay After Deductible

$20 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay

$40 Copay

$150 Copay

$300 Copay

Mail Order 90 Day Supply

$25 Copay

$100 Copay

$375 Copay

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$2,250 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,250

$4,500

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$5,500

$11,000

 

$15,000

$30,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$50 Copay

$50 Copay

 

40%*

40%*

40%*

Urgent Care Services

$50 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

$500 Copay After Deductible

$500 Copay After Deductible, then 40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$750 Copay After Deductible

$0 Copay After Deductible

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

$500 Copay After Deductible

$0 Copay After Deductible

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

$500 Copay After Deductible

30%*

$500 Copay After Deductible

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$750 Copay After Deductible

$20 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay

$40 Copay

$150 Copay

$300 Copay

Mail Order 90 Day Supply

$25 Copay

$100 Copay

$375 Copay

Not Available

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$5,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Family

 

$9,200

$18,400

 

$15,000

$30,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay

$90 Copay

$90 Copay

 

40%*

40%*

40%*

Urgent Care Services

$75 Copay

40%*

Complex Imaging: MRI/CT/PET Scans

$500 Copay After Deductible

$500 Copay After Deductible

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$2,000 Copay After Deductible

$0 Copay After Deductible

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

$1,000 Copay After Deductible

$0 Copay After Deductible

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

$500 Copay After Deductible

30%*

$500 Copay After Deductible

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$2,000 Copay After Deductible

$30 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Retail 30 Day Supply

$10 Copay

$40 Copay

$150 Copay

$300 Copay

Mail Order 90 Day Supply

$25 Copay

$100 Copay

$375 Copay

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 844-855-0619