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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

Orchard Health Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Individual

Family

 

$2,000

$5,000

 

$5,000

$10,000

Out-of-Pocket Maximum

Individual

Family

 

$6,900

$13,800

 

$13,800

$27,600

Preventive Care Services

$0

50%*

Office Visits

Primary Office Visit - Orchard Heath

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$0 Copay

30%*

$60 Copay

$60 Copay

 

50%*

50%*

50%*

50%*

Urgent Care Services

Orchard Health

Non-Orchard Health

 

$0 Copay

$150 Copay

 

50%*

50%*

Titan MRI

Freestanding Facility Imaging

Imaging at Hospital

$100 Copay

$500 Copay

$1,000 Copay

$100 Copay

50%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Emergency Services**

Emergency Room - Referred by Orchard Health

Emergency Room

Emergency Medical Transportation

 

$500 Copay

30%*

30%*

 

50%*

50%*

50%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$60 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$10 Copay

$40 Copay

$60 Copay

Not Covered

Mail Order 90 Day Supply

$20 Copay

$80 Copay

$120 Copay

Not Covered

NOTE: * Coinsurance After Deductible

**True emergencies covered at in-network level

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

 

 

 

 

 

 

Base Plan

In-Network

Out-Of-Network

Calendar Year Deductible

Individual

Family

 

$6,000

$15,000

 

$9,000

$18,000

Out-of-Pocket Maximum

Individual

Family

 

$8,150

$15,300

 

$15,300

$30,600

Preventive Care Services

$0 Copay

50%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

$75 Copay

$125 Copay

$125 Copay

 

50%*

50%*

50%*

Urgent Care Services

$150 Copay

50%*

Titan MRI

Freestanding Facility Imaging

Imaging at Hospital

$100 Copay

$500 Copay

$1,000 Copay

$100 Copay

50%*

50%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Outpatient Procedures

Facility Fee

Physician Fee

 

30%*

30%*

 

50%*

50%*

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

30%*

30%*

 

50%*

50%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

30%*

$125 Copay

 

50%*

50%*

Prescription Drug Coverage

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

$25 Copay

$80 Copay

$100 Copay

Not Covered

Mail Order 90 Day Supply

$50 Copay

$160 Copay

$200 Copay

Not Covered

NOTE: * Coinsurance After Deductible

**True emergencies covered at in-network level

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

 

 

 

 

 

 


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