Plan Details

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.

Summary Of Medical Benefits

Minimum Essential Coverage Plan

In-Network

Out-Of-Network

Deductibles

Individual

Family

 

N/A

N/A

 

N/A

N/A

Out-Of-Pocket Maximum

Individual

Family

 

N/A

N/A

 

N/A

N/A

Preventive Care

No Charge

No Coverage

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

Retail 30 Day Supply

No Coverage

No Coverage

No Coverage

Mail Order 90 day Supply

No Coverage

No Coverage

No Coverage

Urgent Care Services

No Coverage

No Coverage

Inpatient & Outpatient Hospital Services

No Coverage

No Coverage

Emergency Room Services

Emergency Medical Transportation

No Coverage

No Coverage

No Coverage

No Coverage

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

No Coverage

No Coverage

 

No Coverage

No Coverage

Prescription Drug Coverage

Preventive

Generic

Preferred brand

Non-preferred brand

Specialty

100% covered

No Charge

No Coverage

No Coverage

No Coverage

No Coverage

No Coverage

No Charge

No Coverage

No Coverage

No Coverage

No Coverage

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

 

 


If you prefer talking with a HealthEZ representative, call 1-844-449-5535