|
Plan Name |
WiseEssentials |
|
PCY = per calendar year |
Preferred Provider |
Non-Preferred
Provider |
|
Lifetime Maximum |
$2 million per individual |
Annual Deductible
Per
individual PCY;
choose one of the 3 deductible options shown
the deductible applies to all expenses unless otherwise noted |
$1,750 or
$2,500 or
$3,500 |
2x
(times) the
Preferred Provider deductible |
Coinsurance
Benefit
paid by LifeWise Health Plan
unless otherwise noted |
75% |
50% |
Annual Coinsurance Maximum
Per
individual PCY |
$5,000 |
Unlimited |
Annual Out-of-Pocket Maximum
Per
individual PCY; includes annual deductible and coinsurance maximum; once the
out-of-pocket maximum is met,
Preferred Providers are covered in full |
$6,750
($1,750 deductible)
$7,500 ($2,500 deductible)
$8,500 ($3,500 deductible) |
Unlimited |
Preventive Care Exam
Includes routine medical exam,
sports exam, men's and women's
health exam and well-baby exam
Preferred Provider: no deductible for first 6 shared visits*
per person PCY (deductible applies to Non-Preferred Provider visits) |
75% |
50% |
|
* first 6
visits shared between preventive care exams, office visits and
naturopathy |
Preventive Screening
Includes Pap smear, PSA testing, home colon cancer screening,
cholesterol screening and bone density test |
100%
no deductible |
50% |
|
Mammography |
75%
no
deductible |
50% |
|
Immunization |
Not covered |
Office Visit
including Urgent Care
Preferred Provider: no deductible for first 6 shared visits*
per person PCY (deductible applies to Non-Preferred Provider visits) |
75% |
50% |
Naturopathy
Preferred Provider: no deductible for first 6 shared visits*
per person PCY (deductible applies to Non-Preferred Provider visits) |
75% |
50% |
|
|
 |
|
Plan Name |
WiseEssentials |
|
PCY = per calendar year |
Preferred Provider |
Non-Preferred
Provider |
Spinal (Chiropractic) Manipulation
12 visits limit per
calendar year |
100% after $25
copay per visit
no
deductible |
50% |
Acupuncture
12 visits limit per
calendar year |
100% after $25
copay per visit
no
deductible |
50% |
Mental Health
Outpatient Office Visit
6 visits limit per
calendar year |
75%
no
deductible |
50% |
Outpatient Diagnostic
Imaging (X-Ray) and Lab Services |
75%
no deductible for
$1,750 deductible plan only
after deductible for
$2,500 and $3,500
deductible plans |
50% |
|
Other Outpatient & Inpatient Professional Services |
75% |
50% |
|
Inpatient & Outpatient Facility Care |
75% |
50% |
|
Maternity |
Not covered |
Mental Health
Inpatient Facility Care
6 days limit per
calendar year |
75% |
50% |
|
Pharmacy |
Not covered
(Discount Program available;
click here for details) |
|
Vision - Routine Exam |
Not covered |
|
Vision Hardware |
Not covered |
Emergency Room Care
$100 copay
per emergency room
visit;
copay waived if admitted |
75% |
Ambulance Transportation
Air - unlimited
Ground - $5,000
limit PCY |
75% |
Skilled Nursing Facility
45 days limit per calendar
year |
75% |
50% |
|
Durable Medical Equipment and Prosthetics |
Not covered |
Home Health Care
130 visits limit per calendar year |
75% |
50% |
Hospice Care
Inpatient: 10 days limit PCY
Respite: 240
hours limit PCY |
75% |
50% |
|
|
|
|
Plan Name |
WiseEssentials |
|
PCY = per calendar year |
Preferred Provider |
Non-Preferred
Provider |
Rehabilitation
Includes physical,
occupational, massage and speech therapy; cardiac & pulmonary
rehabilitation
Inpatient: 8 days limit PCY Outpatient: 20 visits limit PCY |
75% |
50% |
Transplants
(Organ & Bone Marrow)
12-month waiting period
$250,000 lifetime maximum |
75% |
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. |
