|
PCY = per calendar year |
Preferred Provider |
Non-Preferred
Provider |
|
Plan Name |
WiseChoices 20 |
WiseChoices 30 |
WiseChoices
20 & 30 |
|
Lifetime Maximum |
$2 million per individual |
Annual Deductible
Per individual PCY
(family limit = 3x individual deductible)
the deductible applies to all expenses unless otherwise noted |
$1,000 |
$1,500 |
$3,000 |
Coinsurance
Benefit
paid by LifeWise Health Plan
unless otherwise noted |
80% |
70% |
50% |
Annual Coinsurance Maximum
Per
individual PCY (family limit = 3x individual coinsurance maximum) |
$8,500 |
Unlimited |
Annual Out-of-Pocket Maximum
Per
individual PCY (family limit = 3x individual out-of-pocket maximum); includes annual deductible and coinsurance maximum; once the
out-of-pocket maximum is met,
Preferred Providers are covered in full |
$9,500 |
$10,000 |
Unlimited |
Preventive Care Exam
Includes routine medical exam,
sports exam, men's and women's
health exam and well-baby exam
No deductible for Preferred Providers |
100%
after $30 copay |
50% |
Preventive Screening
Includes Pap smear, PSA testing, home colon cancer screening,
cholesterol screening and bone density test
No deductible for Preferred Providers |
100% |
50% |
|
|
|
|
PCY = per calendar year |
Preferred Provider |
Non-Preferred
Provider |
|
Plan Name |
WiseChoices 20 |
WiseChoices 30 |
WiseChoices
20 & 30 |
Mammography
No deductible for Preferred Providers |
80% |
70% |
50% |
Immunization
No deductible for Preferred Providers |
100% |
Not covered |
Office Visit
including Urgent Care
No deductible for Preferred Providers |
100%
after $30 copay |
50% |
Naturopathy
No deductible for Preferred Providers |
100%
after $30 copay |
50% |
Spinal (Chiropractic) Manipulation
12 visit limit
per calendar year
No deductible for Preferred Providers |
100%
after $25 copay |
50% |
Acupuncture
12 visit limit
per calendar year
No deductible for Preferred Providers |
100%
after $25 copay |
50% |
Mental Health
Outpatient Office Visit
6 visits limit
per calendar year
No deductible for Preferred Providers |
100%
after $30 copay |
50% |
|
|
|
|
PCY = per calendar year |
Preferred Provider |
Non-Preferred
Provider |
|
Plan Name |
WiseChoices 20 |
WiseChoices 30 |
WiseChoices
20 & 30 |
Outpatient Diagnostic
Imaging (X-Ray) and Lab Services |
80% |
70% |
50% |
|
Other Outpatient & Inpatient Professional Services |
80% |
70% |
50% |
|
Inpatient & Outpatient Facility Care |
80% |
70% |
50% |
Maternity
Including prenatal care |
80% |
70% |
50% |
Mental Health
Inpatient Facility Care
6 days limit per
calendar year |
80% |
70% |
50% |
Pharmacy - Retail
up to 30 day supply per
copay
No deductible |
You pay the
copay shown below*
Preferred Provider:
$10 / $45 / 50%
Non-Preferred Provider: same as above + 40% |
Pharmacy - Mail Service
up to 90 day supply per
copay
No deductible |
You pay the
copay shown below*
Preferred Provider:
$25 / $112.50 / 45%
Non-Preferred Provider: same as above + 40% |
|
*
copay for generic / preferred brand-name / non-preferred brand-name drugs. Benefit for generic drugs
is unlimited. Benefit for all brand name drugs is limited to $3,000
per person, per calendar year. |
Vision -
Routine Exam
One
exam per 2 calendar years
No deductible |
100% |
Vision Hardware
Frames,
lenses and contact lenses
No deductible |
100% to $200
maximum benefit per 2 calendar years |
|
|
|
|
PCY = per calendar year |
Preferred Provider |
Non-Preferred
Provider |
|
Plan Name |
WiseChoices 20 |
WiseChoices 30 |
WiseChoices
20 & 30 |
Emergency Room Care
$100 copay
per emergency room
visit;
copay waived if admitted |
WiseChoices 20 - 80% |
|
WiseChoices 30 -
70% |
Ambulance Transportation
Air - unlimited
Ground - $5,000
limit PCY |
WiseChoices 20 - 80% |
|
WiseChoices 30 -
70% |
Skilled Nursing Facility
45 days limit PCY |
80% |
70% |
50% |
Durable Medical Equipment and Prosthetics
$5,000 limit per calendar year |
80% |
70% |
50% |
Home Health Care
130 visits limit per calendar year |
80% |
70% |
50% |
Hospice Care
Inpatient: 10 days PCY
Respite: 240
hours limit PCY |
80% |
70% |
50% |
Rehabilitation
Includes physical,
occupational, massage and speech therapy; cardiac & pulmonary
rehabilitation
Inpatient: 8 days limit PCY Outpatient: 20 visits limit PCY |
80% |
70% |
50% |
Transplants
(Organ & Bone Marrow)
12-month waiting period
$250,000 lifetime maximum |
80% |
70% |
Not covered |
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) |
|
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, LifeWise Health Plan 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. |
