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Not all coverage is the right coverage.

The healthcare coverage you need is probably very different than the coverage some of your co-workers need. 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. That’s why HealthEZ provides multiple coverage options, so you’re never caught paying too much money, or worse, having too little coverage.

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Summary of Medical Benefits

America’s PPO Copay Plan (Copay)

In-Network

Out-of-Network

Embedded Deductible

Individual

Individual under Family

Family

 

$2,500

$2,500

$7,500

 

$5,000

$5,000

$15,000

Embedded Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$5,000

$5,000

$10,000

 

$15,000

$15,000

$30,000

Preventative Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$25 Copay

$25 Copay

 

50%*

50%*

50%*

Urgent Care Services

$25 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

25%*

25%*

25%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

25%*

$25 Copay

 

50%*

50%*

Teledoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$12 Copay

$50 Copay

$90 Copay

Not Covered

Mail Order 90 Day Supply

$24 Copay

$100 Copay

$180 Copay

Not Covered

* Coinsurance after deductible

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

 

 

 

 

America’s PPO 0% Coinsurance Plan (HSA1)

In-Network

Out-of-Network

Embedded Deductible

Individual

Individual under Family

Family

 

$3,500

$3,500

$7,000

 

$7,000

$7,000

$14,000

Embedded Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$3,500

$3,500

$7,000

 

$10,500

$10,500

$21,000

Preventative Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

50%*

50%*

50%*

Urgent Care Services

0%*

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Teledoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

0%*

0%*

0%*

Not Covered

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Covered

* Coinsurance after deductible

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

 

 

 

 

America’s PPO 25% Coinsurance Plan (HSA2)

In-Network

Out-of-Network

Embedded Deductible

Individual

Individual under Family

Family

 

$3,500

$3,500

$7,000

 

$7,000

$7,000

$14,000

Embedded Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$6,500

$6,500

$13,000

 

$19,500

$19,500

$39,000

Preventative Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

25%*

25%*

25%*

 

50%*

50%*

50%*

Urgent Care Services

25%*

50%*

Complex Imaging: MRI/CT/PET Scans

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

25%*

25%*

25%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

25%*

25%*

 

50%*

50%*

Teledoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

25%*

25%*

45%*

Not Covered

Mail Order 90 Day Supply

25%*

25%*

45%*

Not Covered

* Coinsurance after deductible

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

 

 

 

 

America’s PPO Elite Copay Plan (ELITE COPAY)

In-Network

Out-of-Network

Embedded Deductible

Individual

Individual under Family

Family

 

$2,500

$2,500

$7,500

 

$5,000

$5,000

$15,000

Embedded Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$5,000

$5,000

$10,000

 

$15,000

$15,000

$30,000

Preventative Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$25 Copay

$25 Copay

$25 Copay

 

50%*

50%*

50%*

Urgent Care Services

$25 Copay

50%*

Complex Imaging: MRI/CT/PET Scans

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

25%*

25%*

25%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

25%*

$25 Copay

 

50%*

50%*

Teledoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$12 Copay

$50 Copay

$90 Copay

Not Covered

Mail Order 90 Day Supply

$24 Copay

$100 Copay

$180 Copay

Not Covered

* Coinsurance after deductible

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

 

 

 

 

America’s PPO Elite 0% Coinsurance Plan (ELITE HSA1)

In-Network

Out-of-Network

Embedded Deductible

Individual

Individual under Family

Family

 

$3,500

$3,500

$7,000

 

$7,000

$7,000

$14,000

Embedded Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$3,500

$3,500

$7,000

 

$10,500

$10,500

$21,000

Preventative Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

0%*

0%*

0%*

 

50%*

50%*

50%*

Urgent Care Services

0%*

50%*

Complex Imaging: MRI/CT/PET Scans

0%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

0%*

0%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

0%*

0%*

0%*

0%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

0%*

0%*

 

50%*

50%*

Teledoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

0%*

0%*

0%*

Not Covered

Mail Order 90 Day Supply

0%*

0%*

0%*

Not Covered

* Coinsurance after deductible

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

 

 

 

 

America’s PPO Elite 25% Coinsurance Plan (ELITE HSA2)

In-Network

Out-of-Network

Embedded Deductible

Individual

Individual under Family

Family

 

$3,500

$3,500

$7,000

 

$7,000

$7,000

$14,000

Embedded Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$6,500

$6,500

$13,000

 

$19,500

$19,500

$39,000

Preventative Services

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

25%*

25%*

25%*

 

50%*

50%*

50%*

Urgent Care Services

25%*

50%*

Complex Imaging: MRI/CT/PET Scans

25%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

25%*

25%*

 

50%*

50%*

Emergency Room Services

Emergency Medical Transportation

25%*

25%*

25%*

25%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

25%*

25%*

 

50%*

50%*

Teledoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

 

$10 Copay

$10 Copay

$10 Copay

$10 Copay

$10 Copay

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

25%*

25%*

45%*

Not Covered

Mail Order 90 Day Supply

25%*

25%*

45%*

Not Covered

* Coinsurance after deductible

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

 

 

 

 

If you prefer talking with a HealthEZ representative, call 844-660-2444