|
Plan Name |
WiseSavings |
|
PCY = per calendar
year |
Preferred Provider |
Non-Preferred
Provider |
|
Lifetime Maximum |
$2 million per individual |
Annual Deductible
PCY;
choose one of the
2 deductible options shown for individual or family coverage
the deductible applies to all expenses unless
specified |
Individual Coverage
$1,750 or $3,000
Family Coverage
$3,500 or $6,000 |
Coinsurance
Benefit
paid by LifeWise Health Plan
unless otherwise noted |
80% |
60% |
Annual Coinsurance Maximum
Per
calendar year |
Individual
Coverage
$2,500 ($1,750 deductible)
$1,750 ($3,000 deductible) |
Unlimited |
|
Family
Coverage
$5,000 ($3,500 deductible)
$3,500 ($6,000 deductible) |
Annual Out-of-Pocket Maximum
PCY;
includes annual deductible and coinsurance maximum; once the
out-of-pocket maximum is met, Preferred Providers are covered in full |
Individual
Coverage
$4,250 ($1,750 deductible)
$4,750 ($3,000 deductible) |
Unlimited |
|
Family
Coverage
$8,500 ($3,500 deductible)
$9,500 ($6,000 deductible) |
Preventive Care Exam
Includes routine medical exam,
sports exam, men's and women's
health exam and well-baby exam |
100%
no deductible
$300 maximum benefit
per person, per calendar year |
Not covered |
Preventive Screening
Includes Pap smear, PSA testing, home colon cancer screening,
cholesterol screening and bone density test |
80% |
60% |
|
Mammography |
80%
no deductible |
60% |
|
Immunization |
100%
no deductible |
Not covered |
|
Office Visit
including Urgent Care |
80% |
60% |
|
Naturopathy |
80% |
60% |
|
|
 |
|
Plan Name |
WiseSavings |
|
PCY = per calendar
year |
Preferred Provider |
Non-Preferred
Provider |
Spinal (Chiropractic) Manipulation
12 visits limit per calendar
year |
80% |
60% |
Acupuncture
12 visits limit per calendar
year |
80% |
60% |
Mental Health
Outpatient Office Visit
6 visits limit per calendar
year |
80% |
60% |
|
Other Outpatient & Inpatient Professional Services |
80% |
60% |
Outpatient Diagnostic
Imaging (X-Ray) and Lab Services |
80% |
60% |
|
Inpatient & Outpatient Facility Care |
80% |
60% |
|
Maternity |
Not covered |
Mental Health
Inpatient Facility Care
6 days limit per calendar
year |
80% |
60% |
|
Pharmacy |
Not covered
(Discount Program available;
click here for details) |
|
Vision - Routine Exam |
Not covered |
|
Vision Hardware |
Not covered |
|
Emergency Room Care |
80% |
Ambulance Transportation
Air - unlimited
Ground - $5,000
limit PCY |
80% |
Skilled Nursing Facility
20 days limit per calendar
year |
80% |
60% |
Durable Medical Equipment and Prosthetics
$5,000 limit per calendar
year |
80% |
60% |
Home Health Care
120 visits limit per calendar
year |
80% |
60% |
Hospice Care
Inpatient: 10 days limit PCY
Respite: 240
hours limit PCY |
80% |
60% |
Rehabilitation
Includes physical,
occupational, massage and speech therapy; cardiac & pulmonary
rehabilitation
Inpatient: 10 days limit PCY Outpatient: 15 visits limit PCY |
80% |
60% |
|
|
|
|
Plan Name |
WiseSavings |
|
PCY = per calendar
year |
Preferred Provider |
Non-Preferred
Provider |
Transplants
(Organ & Bone Marrow)
12-month waiting period
$250,000 lifetime maximum |
80% |
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. |
