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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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2024 Summary of Medical Benefits

APPO/Aetna HSA Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual Coverage

Individual Under Family Coverage

Individual + Spouse

Individual + Child(ren)

Family Coverage

 

$2,750

$3,200

$4,000

$4,000

$5,500

 

NA

NA

NA

NA

NA

Out-of-Pocket Maximum

Individual Coverage

Individual Under Family Coverage

Individual + Spouse

Individual + Child(ren)

Family Coverage

 

$5,000

$5,000

$8,250

$8,250

$10,000

 

NA

NA

NA

NA

NA

Preventive Care

No Charge

Not Covered

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

20%*

20%*

20%*

 

Not Covered

Not Covered

Not Covered

Hospital Services

20%*

Not Covered

Emergency Services**

Emergency Room Services

Emergency Medical Transportation

 

20%*

20%*

 

Not Covered

Not Covered

Urgent Care Services

20%*

Not Covered

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

 

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

 

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

Not Covered

Not Covered

Prescription Drug Coverage

Preventative

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

No Charge

$10 Copay*

$45 Copay*

$90 Copay*

10%*

Mail Order 90 Day Supply

No Charge

$20 Copay*

$90 Copay*

$180 Copay*

Not Available

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

* After Deductible

** Covered as in-network in true-emergency

 

 

 

 

 

 

Elite Network HSA Plan

In-Network

Out-of-Network

Calendar Year Deductible

Individual Coverage

Individual Under Coverage With Dependents

Employee + Spouse

Employee + Child(ren)

Family Coverage

 

$2,750

$3,200

$4,000

$4,000

$5,500

 

NA

NA

NA

NA

NA

Out-of-Pocket Maximum

Individual Coverage

Individual Under Family Coverage

Individual + Spouse

Individual + Child(ren)

Family Coverage

 

$5,000

$5,000

$8,250

$8,250

$10,000

 

NA

NA

NA

NA

NA

Preventive Care

No Charge

Not Covered

Office Visits

Primary Services

Specialist Services

Chiropractic Services

 

20%*

20%*

20%*

 

Not Covered

Not Covered

Not Covered

Hospital Services

20%*

Not Covered

Emergency Services**

Emergency Room

Emergency Medical Transportation

 

20%*

20%*

 

Not Covered

Not Covered

Urgent Care Services

20%*

Not Covered

Teladoc Services

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, initial evaluation

Mental Health - Psychiatrist, ongoing session

 

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

 

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

$20 fees applied to deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

Not Covered

Not Covered

Prescription Drug Coverage

Preventative

Generic

Preferred brand

Non-preferred brand

Specialty

Retail 30 Day Supply

No Charge

$10 Copay*

$45 Copay*

$90 Copay*

10%*

Mail Order 90 Day Supply

No Charge

$20 Copay*

$90 Copay*

$180 Copay*

Not Available

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

* After Deductible

** Covered as in-network in true-emergency

 

 

 

 

 

 

Summary of Dental Benefits

In-Network and Out-of-Network

Dental Only Premiums

Employee

Employee + Spouse

Employee + Child

Family

$40

$40

$90

$75

$110

Calendar Year Deductible

Individual Coverage

Employee + Spouse

Employee + Child(ren)

Family Coverage

 

$50

$75

$75

$100

Annual Maximum/ individual

$2,000

Orthodontic Lifetime Maximum/ individual

$2,000

Preventive/Diagnostic Care

Dental Exams & Cleanings

Fluoride Treatments

Preventative X-Ray

Full Mouth (Panoramic) X-Ray

 

No Charge

No Charge

No Charge

No Charge

Basic Services

Amalgam, & Composite fillings

Sealants (up to age 16)

Simple Extractions

Oral Sugery

Periodontics & Endodontics

 

20%*

20%*

20%*

20%*

20%*

Major Services

Crowns

Inlays & Onlays

Pontics

Dental Implant

 

50%*

50%*

50%*

50%*

Prosthetics

Bridges

Dentures

Partial Dentures

 

50%*

50%*

50%*

Orthodontics

For dependents under age 16

 

50%*

NOTES: This serves as a summary of your benefit plan only. Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions.

* After deductible

 

 

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