Summary of Medical Benefits
$5,000 HSA Plan
In-Network
Out-of-Network
|
Deductible Individual Family |
$5,000 $10,000 |
$10,000 $20,000 |
|
Out-of-Pocket Maximum Individual Family |
$5,000 $10,000 |
$10,000 $20,000 |
|
Preventive Care 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 Emergency Medical Transportation |
0%* 0%* |
0%* 50%* |
|
Mental Health/Chemical Dependency Inpatient Office Visit |
0%* 0%* |
50%* 50%* |
|
Prescription Drug Coverage Generic Preferred Brand Non-Preferred Brand Specialty Drugs |
Retail 30 Day Supply $20 Copay after Deductible $40 Copay after Deductible 20%* 20%* |
Mail Order 90 Day Supply $40 Copay after Deductible $80 Copay after Deductible 20%* Not Available |
|
NOTE: * Coinsurance after deductible Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions |
|
|
$1,000 HSA Plan
In-Network
Out-of-Network
|
Deductible Individual Family |
$1,000 $2,000 |
$2,000 $4,000 |
|
Out-of-Pocket Maximum Individual Family |
$6,000 $12,000 |
$12,000 $24,000 |
|
Preventive Care Services |
No Charge |
50%* |
|
Office Visits Primary Office Visit Specialist Office Visit Chiropractic Visit |
$25 Copay $50 Copay $50 Copay |
50%* 50%* 50%* |
|
Urgent Care Services |
$100 Copay |
50%* |
|
Complex Imaging: MRI/CT/PET Scans |
20%* |
50%* |
|
Inpatient Hospital Care Facility Fee Physician Fee |
20%* 20%* |
50%* 50%* |
|
Outpatient Procedures Facility Fee Physician Fee |
20%* 20%* |
50%* 50%* |
|
Emergency Room Emergency Medical Transportation |
$300 Copay 20%* |
$300 Copay 50%* |
|
Mental Health/Chemical Dependency Inpatient Office Visit |
20%* $25 Copay |
50%* 50%* |
|
Prescription Drug Coverage Generic Preferred Brand Non-Preferred Brand Specialty Drugs |
Retail 30 Day Supply $10 Copay $20 Copay $75 Copay $250 Copay |
Mail Order 90 Day Supply $20 Copay $40 Copay $150 Copay Not Available |
|
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 844-612-7386