Compare Plans

Not all coverage is the right coverage.

The healthcare coverage you need is probably very different than the coverage some of your co-workers need. 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. That’s why HealthEZ provides multiple coverage options, so you’re never caught paying too much money, or worse, having too little coverage.

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Summary of Medical Benefits

Bronze Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$6,000

$12,00

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

$6,550

$13,100

 

N/A

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$30 Copay after Deductible

$50 Copay after Deductible

$50 Copay after Deductible

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$75 Copay after Deductible

$75 Copay after Deductible

Complex Imaging: MRI/CT/PET Scans

0%*

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$500 Copay after Deductible

0%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

$200 Copay after Deductible

0%*

 

Not Covered

Not Covered

Emergency Room

Emergency Medical Transportation

$150 Copay after Deductible

$150 Copay after Deductible

$150 Copay after Deductible

$150 Copay after Deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$500 Copay after Deductible

$50 Copay after Deductible

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay after Deductible

$30 Copay after Deductible

$50 Copay after Deductible

$10/$30/$50 Copay after

Deductible

Mail Order 90 Day Supply

$20 Copay after Deductible

$60 Copay after Deductible

$100 Copay after Deductible

Not Covered

 

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

NOTE: * Coinsurance After Deductible

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

 

 

 

 

Gold Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$0

$0

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

$6,350

$12,700

 

N/A

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$40 Copay

$40 Copay

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$40 Copay

$40 Copay

Complex Imaging: MRI/CT/PET Scans

$25 Copay/per visit

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$500 Copay

No Charge

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

$200 Copay

No Charge

 

Not Covered

Not Covered

Emergency Room

Emergency Medical Transportation

$150 Copay

$150 Copay

$150 Copay

$150 Copay

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$500 Copay

$25 Copay

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$30 Copay

$50 Copay

$10/$30/$50 Copay

Mail Order 90 Day Supply

$20 Copay

$60 Copay

$100 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

NOTE: * Coinsurance After Deductible

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

 

 

 

 

Silver Plan

In-Network

Out-of-Network

Deductible

Individual

Family

 

$2,000

$4,000

 

N/A

N/A

Out-of-Pocket Maximum

Individual

Family

 

$6,550

$13,100

 

N/A

N/A

Preventive Care Services

No Charge

Not Covered

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay after Deductible

$40 Copay after Deductible

$40 Copay after Deductible

 

Not Covered

Not Covered

Not Covered

Urgent Care Services

$75 Copay after Deductible

$75 Copay after Deductible

Complex Imaging: MRI/CT/PET Scans

$25 Copay/per visit After Deductible

Not Covered

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$750 Copay after Deductible

0%*

 

Not Covered

Not Covered

Outpatient Procedures

Facility Fee

Physician Fee

 

$75 Copay after Deductible

0%*

 

Not Covered

Not Covered

Emergency Room

Emergency Medical Transportation

$150 Copay after Deductible

$150 Copay after Deductible

$150 Copay after Deductible

$150 Copay after Deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

$750 Copay after Deductible

0%*

 

Not Covered

Not Covered

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay after Deductible

$30 Copay after Deductible

$50 Copay after Deductible

$10/$30/$50 Copay after

Deductible

Mail Order 90 Day Supply

$20 Copay after Deductible

$60 Copay after Deductible

$100 Copay after Deductible

Not Covered

 

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

No Charge

No Charge

No Charge

No Charge

No Charge

 

No Charge

No Charge

No Charge

No Charge

No Charge

NOTE: * Coinsurance After Deductible

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

 

 

 

 

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