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Core Plan Benefits
$2,500 to $10,000 Deductible
This is
a Preferred Provider (PPO) plan that does not require a
referral to see another doctor. As long as you are treated by a PPO
provider when you receive medical care, you'll receive the greater
Preferred Plan benefit (80%).
This plan does not cover prescription
drugs, maternity and vision care expenses. If you'd
like an Asuris plan that covers these expenses, click here for
Asuris's Clarity 70
plan.
Chances are excellent that your doctor is an Asuris Northwest Health PPO
plan provider. Click
here
to see if your doctor or practitioner belongs to the "Preferred"
network (in the "Plan:" drop-down box choose "Asuris
Preferred").
The percentages shown below are the amounts paid by Asuris Northwest
Health.
To download
and/or print a summary
of benefits,
click
here. |
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Plan Name |
Core |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating &
Recognized
Provider |
Annual Deductible
Per
individual PCY;
the maximum deductible per family equals
3 times the individual amount; the deductible applies to all
expenses |
Choose one of the deductibles shown below
$2,500
$5,000
$7,500
$10,000 |
|
Lifetime Maximum |
$2 million per individual |
Annual Out-of-Pocket
Coinsurance Amount
Per
individual PCY;
family out-of-pocket coinsurance amount is met when 3 or more
covered family members reach the equivalent of 3 individual
out-of-pocket coinsurance amounts in a calendar year; once the coinsurance is met, Preferred Plan Providers are covered in full |
$5,000 |
Unlimited |
Preventive Care
No deductible
Routine exams, immunizations, well child care, and routine cancer
screenings including preventive surgeries |
$200 maximum benefit per person per calendar year
(routine colorectal cancer screening not subject to maximum) |
|
80% |
50% |
|
Immunizations |
Covered in
Preventive Care benefit shown above |
|
Office, Home & Outpatient Hospital Visits |
First 4 visits
per calendar year
No deductible
& paid at 100% after $35 copay per visit |
After first 4
visits
paid at 80% after $35 copay
per visit and annual deductible |
After first 4
visits
paid at 50% after $35 copay
per visit and annual deductible |
|
Other Outpatient Professional Services & Inpatient Professional Care |
80% |
50% |
|
Prescription Drugs |
Not covered |
|
Routine Vision Exam |
Not covered |
Vision Hardware
Frames,
lenses and contact lenses |
Not covered |
|
Outpatient Diagnostic Imaging (X-Ray) & Lab Services |
First $400 per
calendar year
No
deductible & paid at 100% |
After first $400
paid at 80% after annual deductible |
After first $400
paid at 50% after annual deductible |
Mammography
No deductible for routine
mammograms
|
80% |
50% |
|
|
 |
|
Plan Name |
Core |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating &
Recognized
Provider |
|
Cancer Screening |
Covered in
Preventive Care benefit shown above |
Prostate Cancer Screening
No deductible for routine
prostate cancer screening
|
80% |
50% |
|
Facility Care (Hospital) Inpatient & Outpatient |
80% |
50% |
Skilled Nursing Facility
30 days limit PCY |
80%* |
Emergency Room Care
$100 copay per emergency room
visit; waived if admitted
to an inpatient facility (see the
Emergency Care paragraph
shown toward the bottom of this page) |
80% |
50% |
Ambulance Services
$2,000
maximum benefit PCY
for ground services |
80%** |
|
Maternity Care |
Not covered |
Spinal and Other Manipulations
10 visits limit
PCY |
80% |
50% |
Acupuncture Services
12 visits limit PCY |
80% |
50% |
|
Naturopathic Services |
80% |
50% |
Home Medical Equipment
$2,500 maximum PCY |
80% |
50% |
|
Prostheses and Orthotics |
80% |
50% |
|
Special Equipment and Supplies |
80% |
|
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|
Plan Name |
Core |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating &
Recognized
Provider |
Home Health Care
130 visits limit PCY |
80% |
Hospice Care
6-month benefit maximum |
80% |
Mental Disorders
Inpatient - 8 days limit PCY
Outpatient - 12 visits limit PCY |
80% |
50% |
Rehabilitation
Including physical,
speech and massage therapy
Maximum benefit PCY:
Inpatient - $4,000
Outpatient - $2,000 |
80% |
50% |
Transplants
12-month waiting period
$250,000 lifetime maximum;
$50,000 per transplant donor organ procurement maximum; $2,500 per
transplant travel and lodging maximum |
80% |
50% |
Occupational Injury
or Disease |
Covered as for any
other condition (limited to partners, proprietors or corporate
officers who are not covered by a Workers' Compensation Act or other
similar law) |
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Pre-Existing Conditions |
A pre-existing
condition is one for which there has been
diagnosis, treatment (including the use of prescribed drugs), or
medical advice within the six month period prior to the effective date
of coverage or a condition for which symptoms existed within the six
month period prior to the date of coverage and for which a prudent
person would have ordinarily sought treatment.
Pre-existing
conditions will not be
covered until a member has been continuously enrolled under this plan
for 9 (nine) months. In some cases, Asuris Northwest Health will apply
credit for pre-existing conditions if the person enrolling has been
covered by a prior group or individual health benefit plan that is
considered "creditable" coverage (i.e., a plan that had benefits as
good or better than this plan), at any time during the 63
(sixty-three) day period immediately preceding the receipt date of the
application. |
* At this time, this
service is provided only by participating and recognized providers.
** At this time, this service is provided only by recognized providers.
Cost
Containment Provisions: All hospital and skilled nursing
facility admissions must be medically necessary. When outside the
service area, preadmission approval
should be obtained to ensure that full plans benefits will be
provided.
Copay: There is a per-visit copay for each office call/home
visit billed as such by a provider in the office, home or hospital
outpatient department (waived for surgery, for radiation and chemotherapy,
for spinal manipulations, or if you are directly admitted to the hospital
as an inpatient). Copays do not apply toward the deductible or to the
out-of-pocket coinsurance amount.
Emergency Care: In the event
of a medical emergency inside the service area, benefits will be provided at
the level specified for a Preferred Plan provider. Benefits for
recognized providers will be based on the recognized provider's actual
charge for the service. Outside the service area, benefits will be
provided at the level specified below.
Care Outside the Service Area:
All care received outside the
service area, whether or not a medical emergency, will be covered at
80% of the allowed amount. Any balances of charges not covered by this
plan will be your responsibility.
Annual Out-of-Pocket Coinsurance Amount: For medically necessary
services rendered by a Preferred Plan, participating, or recognized
provider in the service area, the benefits of this plan will be provided
at the percentage of the allowed amount as specified above after the
deductible has been met. Unless otherwise specified, all benefits are
subject to the annual deductible in addition to any copays and
coinsurance. When you have reached the annual coinsurance maximum for
Preferred Plan or out-of-area provider services only, this plan will
provide benefits at 100%
of the allowed amount for the remainder of the calendar year for
Preferred Plan or out-of-area providers, unless otherwise specified.
Any balances of charges not covered by this plan will be your
responsibility to pay. The annual deductible, copays, outpatient
rehabilitation, and most services provided by
participating or recognized providers do not apply to the annual
coinsurance maximum. The maximum coinsurance amount per family is three
times the individual coinsurance amount.
Waiting Periods: No benefits
are provided for treatment relating to a transplant until you have
been covered under this or a prior plan with Asuris Northwest Health for 12 consecutive
months. No benefits will be provided for preexisting conditions until you have been covered under this plan for
nine consecutive months, unless you were continuously covered for at
least nine months under the immediately preceding creditable plan.
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Important
Information About This Benefit
Summary |
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This is a brief summary of benefits; it is
not a contract or a certificate of coverage. The complete terms of coverage
are determined by the carrier's contract. While we have accurately
represented the information in this Benefit Summary as of the time it was
published, should any discrepancies exist between this Benefit Summary and
the carrier's contract, the carrier's contract shall prevail. Please refer
to the carrier's contract for a complete statement of benefits including
waiting periods, limitations and exclusions.
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