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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2025 Summary of Medical Benefits

Copay Plan Schedule of Benefits

In-Network

Out-of-Network

Deductible

Individual

Individual Under Family

Family

 

$400

$400

$800

 

$400

$400

$800

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$1,400

$1,400

$2,800

 

$2,400

$2,400

$4,800

Preventive Care Services

No charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 copay

$25 copay

20%*

 

30%*

30%*

20%*

Urgent Care Services

$25 copay

$25 copay

Complex Imaging: MRI/CT/PET Scans

10%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

30%*

30%*

Emergency Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

$25 copay

 

30%*

30%*

Prescription Drug Coverage

Preventive Prescriptions

Generic

Preferred brand

Non-preferred brand

Specialty Drugs

Retail 30 Day Supply

No charge

No charge

$35 Copay

$50 Copay

20%*

Mail Order 90 Day Supply

No charge

No charge

$70 Copay

$100 Copay

Not Covered

NOTE: * Coinsurance After Deductible

 

 

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

 

 

HSA Plan Schedule of Benefits

In-Network

Out-of-Network

Deductible

Individual

Individual Under Family

Family

 

$3,500

$3,500

$7,000

 

$4,000

$4,000

$8,000

Out-of-Pocket Maximum

Individual

Individual Under Family

Family

 

$3,500

$3,500

$7,000

 

$5,000

$5,000

$10,000

Preventive Care Services

No charge

30%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

30%*

30%*

30%*

Urgent Care Services

0%*

0%*

Complex Imaging: MRI/CT/PET Scans

0%*

30%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

30%*

30%*

Emergency Room

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

30%*

30%*

Prescription Drug Coverage

Preventive Prescriptions

Generic

Preferred brand

Non-preferred brand

Specialty Drugs

Retail 30 Day Supply

No Charge

0%*

0%*

0%*

0%*

Mail Order 90 Day Supply

No Charge

0%*

0%*

0%*

Not Covered

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 844-302-7778