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

$2,000 Copay Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$4,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$4,500

$9,000

 

$10,000

$20,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$40 Copay

$40 Copay

30%*

 

50%*

50%*

50%*

Urgent Care Services

$40 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

30%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

30%*

30%*

30%*

30%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$40 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$20 Copay

$50 Copay

$75 Copay

30% Coinsurance up to $550

Mail Order 90 Day Supply

$60 Copay

$150 Copay

$225 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

NOTE: * Coinsurance After Deductible

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

 

 

 

 

$5,000 HSA Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$5,000

$10,000

 

$7,500

$15,000

Out-of-Pocket Maximum

Individual

Family

 

$8,050

$16,100

 

$12,500

$25,000

Preventive Care Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

25%*

25%*

25%*

 

50%*

50%*

50%*

Urgent Care Services

25%*

50%*

Complex Imaging: MRI/CT/PET Scans

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

25%*

25%*

25%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

25%*

25%*

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

25%*

25%*

25%*

25%*

Mail Order 90 Day Supply

25%*

25%*

25%*

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

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 844-804-8121