Plan Details

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.

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Summary Of Medical Benefits

Minimum Essential Coverage Plan

In-Network

Out-Of-Network

Deductible

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

 

No Coverage

No Coverage

No Coverage

 

No Coverage

No Coverage

No Coverage

Urgent Care Services

No Coverage

No Coverage

Complex Imaging: MRI/CT/PET Scans

No Coverage

No Coverage

Inpatient Hospital Care

No Coverage

No Coverage

Outpatient Procedures

No Coverage

No Coverage

Emergency Services

Emergency Room

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

Retail 30 Day Supply

No Charge

No Coverage

No Coverage

No Coverage

No Coverage

Mail Order 90 day Supply

No Charge

No Coverage

No Coverage

No Coverage

No Coverage


If you prefer talking with a HealthEZ representative, call 844-660-2451