Deductible, coinsurance and copay represent what you pay. All coinsurance amounts are based on maximum allowable amounts.
Benefits apply after calendar year deductible is met, unless otherwise noted as “no deductible,” “copay,” or “covered in full.”
| LifeWise HSA-Qualified |
Preferred Providers |
Non-Preferred Providers |
| Annual Deductible PCY (choose one) |
Individual: $3,000
Family: $6,000* |
Individual: $5,950
Family: $11,900* |
Shared with preferred provider deductible |
| Coinsurance1 (what you pay) |
25% |
0% |
50% |
| Annual Coinsurance Maximum2 |
$2,950 Individual $5,900 Family |
$0 |
$5,900 Individual $11,800 Family2 |
| Lifetime Maximum |
$2,000,000 |
| Covered Services |
Preferred Providers |
Non-Preferred & extended providers |
| Preventive Care
|
Preventive Care Exams
(routine medical exam, sports physical and women’s health exams/well baby) |
Deductible waived, then 25% |
Deductible waived, then covered in full |
Deductible, then 50% |
Preventive Screenings
(includes Pap smear, PSA testing, home colon cancer screening, cholesterol screening and bone density test) |
Covered in full3 |
Covered in full3 |
| Immunizations |
| Professional Care
|
| Office Visit including Urgent Care |
Deductible, then 25% |
Deductible, then covered in full |
Deductible, then 50% |
| Other Outpatient and Inpatient Professional Services |
| Alternative Care
|
Chiropractic
12 visits PCY
(visits shared with Acupuncture) |
Deductible, then 25% |
Deductible, then covered in full |
Deductible, then 50% |
Acupuncture
12 visits PCY
(visits shared with Chiropractic) |
| Naturopathy |
| Diagnostic Services
|
| Outpatient Diagnostic Imaging and Lab Services |
Deductible, then 25% |
Deductible, then covered in full |
Deductible, then 50% |
| Mammography |
Covered in full3 |
Covered in full3 |
| Pharmacy |
| Retail Pharmacy - Generics4 (30-day supply) |
Deductible, then 25%
($5,000 PCY limit)
|
Deductible, then covered in full
($5,000 PCY limit)
|
Not Covered
|
| Mail Service Pharmacy - Generics4 (90-day supply) |
| Emergency Care
|
| Emergency Room Care |
Deductible, then 25% |
Deductible, then covered in full |
Preferred provider deductible, then preferred provider coinsurance |
Ambulance Transportation
Air (unlimited); Ground ($5,000 PCY limit) |
| Facility Care
|
| Inpatient Facility Care |
Deductible, then 25% |
Deductible, then covered in full |
Deductible, then 50% |
| Outpatient Facility Care |
| Skilled Nursing Facility 45 days PCY; includes room and board, ancillaries and professional fees |
| Maternity |
| Maternity Care |
Deductible, then 25% |
Deductible, then covered in full |
Deductible, then 50% |
| Vision Care
|
Routine Vision Exam
1 exam PCY |
Deductible, then 25% |
Deductible, then covered in full |
Preferred provider deductible, then preferred provider coinsurance |
| Other Services
|
| Supplies, Equipment and Prosthetics $5,000 PCY |
Deductible, then 25% |
Deductible, then covered in full |
Deductible, then 50% |
| Home Health Care 130 visits PCY |
| Hospice Care Inpatient: 10 days, Respite: 240 hours per 6 months lifetime maximum |
| Rehabilitation (includes Physical, Occupational & Speech Therapy, Cardiac & Pulmonary Rehab; & Chronic Pain) Outpatient: 20 visits PCY; Inpatient:
8 days PCY |
| Transplants (Organ & Bone Marrow) 12-month waiting period; $250,000 Lifetime Benefit |
| Alcohol Dependency Treatment |
This optional benefit is available at an additional cost. It is limited to $4,500 in any 24 consecutive months |
PCY = Per Calendar Year
1 All coinsurance amounts are the member’s percentage of maximum allowable amounts after deductible
2 Does not include deductible
3 Benefits provided at 100% of maximum allowable amounts;
not subject to deductible or coinsurance
4 Certain preventive generic drugs are reimbursed at 100%
* Services for all family members covered under the same HSA-qualified plan get applied to the
same deductible. The family deductible must be met before services are covered for any enrolled family members.
Note: Prosthetics and orthotic devices are a covered service on LifeWise plans and are not subject to a PCY limit.
This is only a summary of major benefits. It is not a contract. |
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