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Clarity Plan Benefits
Clarity
70 and
Clarity
50
$1,000 to $5,000 Deductible
All
plans are Preferred Provider (PPO) plans that do not require a
referral to see another doctor.
The Clarity 70 plan covers prescription
drugs, maternity, preventive care and vision care expenses. The
Clarity 50 plan does not cover these expenses.
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 Clarity benefits,
click on one of the
following plan names:
Clarity 70 or
Clarity 50. |
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Plan Name |
Clarity 70 |
Clarity 50 |
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PCY = per calendar year |
Preferred Plan Provider |
Participating or
Recognized Provider |
Preferred Plan Provider |
Participating or
Recognized
Provider |
Annual Deductible
Per
individual PCY; choose one of the deductibles shown;
the maximum deductible per family equals 3 times the individual
amount; the deductible applies to all expenses unless otherwise
specified |
$1,000
or
$3,000 |
$2,500
or
$5,000 |
|
Lifetime Maximum |
$2 million per individual |
Annual Coinsurance Maximum
Per
individual PCY;
the maximum coinsurance per family
equals 3 times the individual
amount; once the coinsurance is met,
Preferred Plan Providers are covered
in full |
$5,000 |
Unlimited |
$10,000 |
Unlimited |
Preventive Care
No deductible
Routine exams, immunizations, well child care, and routine cancer
screenings including preventive surgeries, such as colonoscopies |
$200 maximum benefit
per person
per calendar year |
Not covered |
|
70% |
50% |
|
Immunizations |
Included in
Preventive Care
shown above |
Not covered |
Office, Home & Outpatient Hospital Visits
No deductible
(Clarity 80 and 70 plans only;
deductible applies to Clarity 50 plan) |
100%
after $30
per-visit
copay |
100%
after $40
per-visit
copay |
50% |
|
Other Outpatient Professional Services & Inpatient Professional Care |
70% |
50% |
50% |
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|
 |
|
Plan Name |
Clarity 70 |
Clarity 50 |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating or
Recognized Provider |
Preferred Plan Provider |
Participating or
Recognized Provider |
Prescription Drugs***
No
deductible
$3,000
maximum benefit PCY; prescriptions limited to 34-day supply per prescription at a retail
pharmacy or 90-day supply by
mail order |
Generic
Formulary:
100% after $10 retail copay
100% after $20 mail order copay
Brand-Name Formulary: 70%
Non-Formulary: 50% |
Not covered |
Routine Vision Exam
No
deductible
One
exam PCY |
100%
after $30 copay |
100%
after $40 copay |
Not covered |
Vision Hardware
No
deductible
Frames,
lenses and contact lenses |
100%* to $200
maximum benefit
per person PCY |
Not covered |
|
Outpatient Diagnostic Imaging (X-Ray) & Lab Services |
70% |
50% |
50% |
Mammography
No deductible for
routine mammograms
(Clarity 80 and 70 plans only;
deductible applies to Clarity 50 plan) |
70% |
50% |
50% |
|
Cholesterol Screening |
Included in
Preventive Care
shown above |
Not covered |
|
Prostate Cancer Screening |
70% |
50% |
50% |
|
Facility Care (Hospital) Inpatient & Outpatient |
70% |
50% |
50% |
Skilled Nursing Facility
30 days maximum per
calendar year |
70%* |
50%* |
Emergency Room Care
$100 copay
per emergency room
visit; waived if directly admitted
to an inpatient facility (see the
Emergency Care
paragraph
shown toward the bottom of this page) |
70% |
50% |
50% |
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|
Plan Name |
Clarity 70 |
Clarity 50 |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating or
Recognized Provider |
Preferred Plan Provider |
Participating or
Recognized Provider |
Ambulance Services**
$2,000
maximum benefit
PCY for ground services |
70% |
50% |
Maternity Care
Including
prenatal care |
70% |
50% |
Not covered |
Spinal and Other Manipulations
10 visits
limit PCY |
70% |
50% |
50% |
Acupuncture Services
12 visits limit
PCY |
70% |
50% |
50% |
|
Naturopathic Services |
70% |
50% |
50% |
Home Medical Equipment
$2,500 maximum PCY |
70% |
50% |
50% |
|
Prostheses and Orthotics |
70% |
50% |
50% |
|
Special Equipment and Supplies |
70% |
50% |
Home Health Care
130 visits limit PCY |
70% |
50% |
Hospice Care
6-month benefit maximum |
70% |
50% |
Mental Disorders
Inpatient - 8 days limit PCY
Outpatient - 12 visits limit PCY |
70% |
50% |
50% |
Rehabilitation
Including physical,
occupational, speech and massage therapy
Maximum benefit PCY:
Inpatient - $4,000
Outpatient - $2,000 |
70% |
50% |
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 |
70% |
50% |
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, 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 or recognized providers.
** At this time, this service is provided only by recognized providers.
*** Prescriptions obtained from non-participating pharmacies will not be
covered except
outside the service area or for cases of medical
emergency.
Copay: (applies to Clarity 70 plan) 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 coinsurance
maximum.
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.
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% (Clarity 80), 70% (Clarity 70) or 50% (Clarity 50) of the
allowed amount, except benefits for prescription drugs and vision hardware
(Clarity 80 and 70 plans) will be provided at the levels specified. Any
balances of charges not covered by this plan will be your responsibility.
Annual Coinsurance Maximum: 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, prescription drugs and vision hardware (Clarity
80 and
70 plans), 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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