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.

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Summary of Medical Benefits

$3,500 Copay Plan

Tier 1: America's PPO - Elite

Tier 2: America's PPO

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$1,750

$1,750

$5,250

 

$3,500

$3,500

$10,500

 

$7,000

$7,000

$21,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$3,250

$3,250

$6,500

 

$6,500

$6,500

$13,000

 

$19,500

$19,500

$39,000

Preventive Care Services

No Charge

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$20 Copay

$20 Copay

$20 Copay

 

$35 Copay

$35 Copay

$35 Copay

 

50%*

50%*

50%*

Urgent Care Services

$20 Copay

$35 Copay

$35 Copay

Complex Imaging: MRI/CT/PET Scans

10%*

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

25%*

25%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

10%*

10%*

25%*

25%*

25%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

$20 Copay

 

25%*

$35 Copay

 

50%*

50%*

NOTE: * Coinsurance After Deductible

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

 

 

 

 

 

 

$4,500 HSA Plan

Tier 1: America's PPO - Elite

Tier 2: America's PPO

Out-of-Network

Calendar Year Deductible

Individual

Individual Under Family

Family

 

$2,250

$3,300

$4,500

 

$4,500

$4,500

$9,000

 

$9,000

$9,000

$18,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$3,250

$3,300

$6,500

 

$6,500

$6,500

$13,000

 

$19,500

$19,500

$39,000

Preventive Care Services

No Charge

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

10%*

10%*

10%*

 

25%*

25%*

25%*

 

50%*

50%*

50%*

Urgent Care Services

10%*

25%*

25%*

Complex Imaging: MRI/CT/PET Scans

10%*

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

25%*

25%*

 

50%*

50%*

Emergency Room

Emergency Medical Transportation

10%*

10%*

25%*

25%*

25%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

10%*

 

25%*

25%*

 

50%*

50%*

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 844-672-8346