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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 1

In-Network

Out-of-Network

Calendar Year Accumulation

Embedded Deductible

Employee only

Family

 

 

$1,500

$3,000

 

 

$3,000

$6,000

Coinsurance

0%

25%

Embedded Out-of-Pocket Maximum

Employee only

Family

 

$6,000

$12,000

 

$12,000

$24,000

Recuro Telemedicine

100% Covered

100% Covered

Preventive Care

100% Covered

50% Coinsurance

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

$30 Copay

$60 Copay

25%* After Deductible

 

25%* After Deductible

25%* After Deductible

25%* After Deductible

Urgent Care Services

$100 Copay

25%* After Deductible

Emergency Services

Emergency Room

Emergency Medical Transportation

 

$300 Copay After Deductible

0%* After Deductible

 

$300 Copay After Deductible

0%* After Deductible

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

 

0%* After Deductible

$500 Copay After Deductible

 

25%* After Deductible

25%* After Deductible

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

 

$40 Copay After Deductible

$60 Copay After Deductible

$300 Copay After Deductible

 

25%* After Deductible

25%* After Deductible

25%* After Deductible

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

0%* After Deductible

$60 Copay

 

25%* After Deductible

25%* After Deductible

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

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

* Coinsurance

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

An Embedded Deductible means that each individual will only have to meet the individual Deductible before the Plan begins paying benefits for such individual that are subject to a Deductible.

An Embedded Out-of-Pocket Maximum means that each individual will only have to meet the individual out-of-pocket maximum before the Plan begins paying in full for such individual

 

 

 

 

 

 

 

 

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