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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Summary of Medical Benefits

Copay Plan 1

Tier 1: Irwin County/H2B

Tier 2: First Health

Out of Network

Calendar Year Deductible

Individual

Individual under Family

Family

 

$0

$0

$0

 

$5,000

$5,000

$10,000

 

$10,000

$10,000

$20,000

Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$2,500

$2,500

$5,000

 

$8,000

$8,000

$16,000

 

$20,000

$20,000

$40,000

Preventative Services

No Charge

No Charge

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

No Charge

$15 Copay

10%*

 

$45 Copay

$75 Copay

20%*

 

50%*

50%*

50%*

Urgent Care Services

$15 Copay

$75 Copay

50%*

Complex Imaging

CT Scans

MRI/PET Scans

 

$100 Copay

$100 Copay

 

20%*

20%*

 

50%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

10%*

10%*

 

20%*

20%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

10%*

10%*

 

20%*

20%*

 

50%*

50%*

Emergency Room Care

Facility Fee

Physician Fee

Medical Transportation

 

$250 Copay

10%

20%*

 

$250 Copay

20%*

20%*

 

50%*

50%*

50%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

10%*

No Charge

 

20%*

$45 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$40 Copay

$70 Copay

$250 Copay

Mail Order 90 Day Supply

$20 Copay

$80 Copay

$140 Copay

Not Available

 

 

 

 

 

NOTE: * Coinsurance after deductible

** Covered as in-network in true-emergency

 

 

 

 

 

 

If you prefer talking with a HealthEZ representative, call 844-617-2436