Summary of Medical Benefits
$4,000 Copay Plan
In-Network
Out-of-Network
|
Calendar Year Deductible Individual Individual Under Family Family |
$4,000 $4,000 $8,000 |
$12,000 $12,000 $24,000 |
|
Out-of-Pocket Maximum Individual Individual Under Family Family |
$6,000 $6,000 $12,000 |
$24,000 $24,000 $48,000 |
|
Preventive Care Services |
No Charge |
40%* |
|
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
$75 Copay $100 Copay $100 Copay |
40%* 40%* 40%* |
|
Urgent Care Services |
$125 Copay |
$125 Copay |
|
Complex Imaging: MRI/CT/PET Scans |
20%* |
40%* |
|
Inpatient Hospital Care Facility Fee Physician Fee |
20%* 20%* |
40%* 40%* |
|
Outpatient Procedures Facility Fee Physician Fee |
20%* 20%* |
40%* 40%* |
|
Emergency Room Facility Fee Physician Fee Emergency Medical Transportation |
$500 Copay, then 20%* 20%* 20%* |
$500 Copay, then 20%* 20%* 20%* |
|
Mental Health/Chemical Dependency Inpatient Office Visit |
20%* $75 Copay |
40%* 40%* |
|
NOTE: * Coinsurance after deductible Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions |
|
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If you prefer talking with a HealthEZ representative, call 855-290-1412