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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

Copay Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual Coverage

Individual Under Family Coverage

Family Coverage

 

$1,500

$1,500

$3,000

 

$4,500

$4,500

$9,000

Out-of-Pocket Maximum

Individual Coverage

Individual Under Family Coverage

Family Coverage

 

$4,500

$4,500

$9,000

 

$13,500

$13,500

$27,000

Preventive Care

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$35 Copay

$35 Copay

$35 Copay

 

40%*

40%*

40%*

Urgent Care Services

$65 Copay

40%*

Complex Imaging

MRI/CT/PET scans- Free standing Facility

MRI/CT/PET scans- Hospital or outpatient hospital

 

20%*

40%*

 

40%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedure

Facility Fee

Physician Fee

 

40%*

40%*

 

50%*

50%*

Emergency Room Services**

Emergency Medical Transportation**

20%*

20%*

40%*

40%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$35 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$20 Copay

$80 Copay

$150 Copay

30% Coinsurance (Prudent Rx)

Mail Order 90 Day Supply

$40 Copay

$160 Copay

$300 Copay

Not Available

* Coinsurance after deductible

** Covered as in-network in true-emergency

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

 

 

 

 

 

 

HSA Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual Coverage

Individual Under Family Coverage

Family Coverage

 

$3,200

$3,200

$6,400

 

$6,400

$6,400

$12,800

Out-of-Pocket Maximum

Individual Coverage

Individual Under Family Coverage

Family Coverage

 

$4,000

$4,000

$8,000

 

$8,000

$8,000

$16,000

Preventive Care

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

40%*

40%*

40%*

Urgent Care Services

20%*

40%*

Complex Imaging

MRI/CT/PET scans- Free standing Facility

MRI/CT/PET scans- Hospital or outpatient hospital

 

20%*

40%*

 

40%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

40%*

40%*

 

50%*

50%*

Emergency Room Services**

Emergency Medical Transportation**

20%*

20%*

40%*

40%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

40%*

40%*

Prescription Drug Coverage

Preventative Generic

Preventative Preferred Brand

Preventative Non-Preferred Brand

Non-Preventative Generic

Non-Preventative Preferred brand

Non-Preventative Non-preferred brand

Non-Preventative Specialty

Retail 30 Day Supply

$10 Copay

$125 Copay

$250 Copay

20%*

20%*

20%*

20%*

Mail Order 90 Day Supply

$20 Copay

$250 Copay

$500 Copay

20%*

20%*

20%*

Not Available

* Coinsurance after deductible

** Covered as in-network in true-emergency

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

 

 

 

 

 

 

High Value / Elite Network Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual Coverage

Individual Under Family Coverage

Family Coverage

 

$3,200

$3,200

$6,400

 

$6,400

$3,200

$12,800

Out-of-Pocket Maximum

Individual Coverage

Individual Under Family Coverage

Family Coverage

 

$5,000

$5,000

$10,000

 

$10,000

$10,000

$20,000

Preventive Care

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

40%*

40%*

40%*

Urgent Care Services

20%*

40%*

Complex Imaging

MRI/CT/PET scans- Free standing Facility

MRI/CT/PET scans- Hospital or outpatient hospital

 

20%*

40%*

 

40%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

40%*

40%*

 

50%*

50%*

Emergency Room Services**

Emergency Medical Transportation**

20%*

20%*

40%*

40%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

40%*

40%*

Prescription Drug Coverage

Preventative Generic

Preventative Preferred Brand

Preventative Non-Preferred Brand

Non-Preventative Generic

Non-Preventative Preferred brand

Non-Preventative Non-preferred brand

Non-Preventative Specialty

Retail 30 Day Supply

$10 Copay

$125 Copay

$250 Copay

20%*

20%*

20%*

20%*

Mail Order 90 Day Supply

$20 Copay

$250 Copay

$500 Copay

20%*

20%*

20%*

Not Available

* Coinsurance after deductible

** Covered as in-network in true-emergency

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

The High Value Plan / Elite Network Plan utlizes a specific network. All scheduled surgeries should be through Fariview Health System or Twin Cities Orthopedics.

 

 

 

 

 

 

 

 

If you prefer talking with a HealthEZ representative, call 1-800-948-5988