Summary Of Medical Benefits
PPO 4
In-Network
Out-Of-Network
|
Deductible Individual Family |
$2,000 $4,000 |
$4,000 $8,000 |
|
Out of Pocket Maximum Individual Family |
$6,000 $12,000 |
$12,000 $24,000 |
|
Preventive Care Services |
No Charge |
50% Coinsurance |
|
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
$20 Copay $75 Copay 25%* |
50%* 50%* 50%* |
|
Urgent Care Services |
$50 Copay |
50%* |
|
Complex Imaging: MRI/CT/PET Scans |
$300 Copay after Deductible |
50%* |
|
Inpatient Hospital Care Facility Fee Physician Fee |
0%* 0%* |
50%* 50%* |
|
Outpatient Procedures Facility Fee Physician Fee |
$750 Copay after Deductible 0%* |
50%* 50%* |
|
Emergency Room Services Emergency Medical Transportation |
$300 Copay after Deductible No Charge |
$300 Copay after Deductible 0%* |
|
Mental Health/Chemical Dependency Inpatient Office Visit |
0%* $20 Copay |
50%* 50%* |
|
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 Avaialbe |
|
NOTE: * Coinsurance after deductible Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions |
|
|
PPO 6
In-Network
Out-Of-Network
|
Deductible Individual Family |
$5,000 $10,000 |
$5,000 $10,000 |
|
Out of Pocket Maximum Individual Family |
$7,000 $14,000 |
$15,000 $30,000 |
|
Preventive Care Services |
No Charge |
50% Coinsurance |
|
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
$20 Copay $75 Copay 25%* |
50%* 50%* 50%* |
|
Urgent Care Services |
$50 Copay |
50%* |
|
Complex Imaging: MRI/CT/PET Scans |
$300 Copay after Deductible |
50%* |
|
Inpatient Hospital Care Facility Fee Physician Fee |
0%* 0%* |
50%* 50%* |
|
Outpatient Procedures Facility Fee Physician Fee |
$750 Copay after Deductible 0%* |
50%* 50%* |
|
Emergency Room Services Emergency Medical Transportation |
$300 Copay after Deductible No Charge |
$300 Copay after Deductible 0%* |
|
Mental Health/Chemical Dependency Inpatient Office Visit |
0%* $20 Copay |
50%* 50%* |
|
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 Avaialbe |
|
NOTE: * Coinsurance after deductible Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions |
|
|
HDHP 5
In-Network
Out-Of-Network
|
Deductible Individual Family |
$6,900 $13,800 |
$10,000 $20,000 |
|
Out of Pocket Maximum Individual Family |
$7,000 $14,000 |
$15,000 $30,000 |
|
Preventive Care Services |
No Charge |
50% Coinsurance |
|
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
20%* 20%* 20%* |
50%* 50%* 50%* |
|
Urgent Care Services |
20%* |
50%* |
|
Complex Imaging: MRI/CT/PET Scans |
20%* |
50%* |
|
Inpatient Hospital Care Facility Fee Physician Fee |
20%* 20%* |
50%* 50%* |
|
Outpatient Procedures Facility Fee Physician Fee |
20%* 20%* |
50%* 50%* |
|
Emergency Room Services Emergency Medical Transportation |
20%* 20%* |
20%* 20%* |
|
Mental Health/Chemical Dependency Inpatient Office Visit |
20%* 20%* |
50%* 50%* |
|
Prescription Drug Coverage Expanded Preventive Generic Expanded Preventive Preferred Brand Generic Preferred Brand Non-Preferred Brand Specialty |
Retail 30 Day Supply 20% Coinsurance 20% Coinsurance 20%* 20%* 50%* 50%* |
Mail Order 90 Day Supply 20% Coinsurance 20% Coinsurance 20%* 20%* 50%* Not Avaialbe |
|
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 855-255-7060