Plan Details

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

Copay 1 Plan

In Network

Out-of-Network

Embedded Deductible

Employee only

Family

 

$3,000

$6,000

 

$5,000

$10,000

Coinsurance

0%

50%

Embedded Out-of-Pocket Maximum

Employee only

Family

 

$6,750

$13,500

 

$15,000

$30,000

WellVia (a Recuro Health company) Telemedicine Services

no charge

no charge

Preventive Care

No Charge

50% Coinsurance

Office Visits

Primary Services

Specialist Services

Walk In Clinics

Chiropractic Services

 

$20 Copay

$75 Copay

$50 Copay

25%* after Deductible

 

50%* after Deductible

50%* after Deductible

50%* after Deductible

50%* after Deductible

Urgent Care Services

$50 Copay

50%* after Deductible

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

$300 Copay after Deductible

0%* after Deductible

 

$300 Copay after Deductible

0%* after Deductible

Hospital Services

Inpatient Hospital Facility

Outpatient Surgery

 

0%* after Deductible

0%* after Deductible

 

50%* after Deductible

50%* after Deductible

Diagnostic Testing & Imaging

Labs

X-rays

CT/PET/MRI

 

$50 Copay after Deductible

$75 Copay after Deductible

$300 Copay after Deductible

 

50%* after Deductible

50%* after Deductible

50%* after Deductible

Mental Health/Chemical Dependency

Inpatient

Outpatient

 

0%* after Deductible

$75 Copay

 

50%* after Deductible

50%* after Deductible

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 Available

*Coinsurance

 

 

**Covered as In-Network in true emergency

 

 


If you prefer talking with a HealthEZ representative, call 855-255-7060