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.


Plan Details

Copay 1 Plan

In-Network

Out-of-Network

Embedded Deductible

Individual only

Individual under Family

Family

 

$6,000

$6,000

$12,000

 

N/a

N/a

N/a

Coinsurance

0%

N/a

Embedded Out-of-Pocket Maximum

Individual only

Individual under Family

Family

 

$6,600

$6,600

$13,200

 

N/a

N/a

N/a

Recuro Telemedicine Services

100% Covered

100% Covered

Preventive Care

100% Covered

Not Covered

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

$40 Copay

$80 Copay

$40 Copay

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$100 copay

Not Covered

Emergency Services

Emergency Room

Emergency Medical Transportation

 

$300 copay

Deductible, then 100% Covered

 

Not Covered

Not Covered

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

 

Deductible, then 100% Covered

Deductible, then 100% Covered

 

Not Covered

Not Covered

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

 

No Charge

No Charge

$300 Copay

 

Not Covered

Not Covered

Not Covered

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

Deductible, then 100% Covered

$80 Copay

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$20 Copay

$40 Copay

$60 Copay

$20 / $125 / $250 Copay

Mail Order 90 Day Supply

$40 Copay

$80 Copay

$120 Copay

Not Available


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