|
† = Deductible waived.
|
HSA PPO
HSA Qualified
|
| Lifetime Maximum |
$4,000,000
|
| Calendar Year Deductible |
Individual:
|
Family:
|
| |
Preferred
|
Non-Preferred
|
| Coinsurance Maximum Per Individual |
$2,500 ded = $2,500 indiv. 6
$3,500 ded = $1,500 indiv. 6
$5,000 ded = $0 indiv. 6
|
$2,500 ded = $5,000 indiv. 6
$3,500 ded = $3,000 indiv. 6
$5,000 ded = $10,000 indiv. 6
|
| Out-of-Pocket Maximum |
Deductible + Coinsurance Maximum
|
| PREVENTATIVE CARE |
Member Responsibility
|
| |
Preferred
|
Non-Preferred
|
Routine Physical Exams
Well-Baby Care |
Coinsurance 3;
deductible waived
|
Not Covered
|
| Routine Immunizations/Vaccinations |
Coinsurance 3;
deductible waived
|
Not Covered
(except for Flu shots†)
|
| Women’s Routine Mammograms |
Coinsurance 3;
deductible waived
|
40%
|
| Women’s & Men's Annual Health
Exams |
Coinsurance 3;
deductible waived
|
40%
|
| PHYSICIAN PROVIDER SERVICES |
| Office visits |
Coinsurance 3
|
40%
|
| Alternative Care (12 visit PCY Limit) |
Coinsurance 3
(Preferred Providers only)
|
Not Covered
|
| HOSPITAL SERVICES |
Inpatient & Outpatient Surgery
Room & Ancillary Charges
Physician Services |
Coinsurance 3
|
40%
|
| MATERNITY |
All Pre/Post Office Visits & Doctor
Delivery
Hospital Charges |
Coinsurance 3
|
40%
|
| EMERGENCY SERVICES |
| Urgent Care |
Coinsurance 3
|
40%
|
Hospital Emergency Room
Ambulance
($5,000 PCY Limit for Air & Ground) |
Coinsurance 3
|
| OTHER FACILITIES & SERVICES |
Lab & X-ray Services
Medical Supplies & Devices - ($2,500 PCY limit)
Home Health Care - (130 visit PCY limit) |
Coinsurance 3
|
40%
|
Prescription Services
(No Mail Order Program) |
Deductible, then coinsurance 3
except generic cardiac preventive drugs covered in full/deductible waived
|
| Accident Benefit |
Paid as any other illness subject to
deductible/coinsurance
|
| SUPPLEMENTAL BENEFIT OPTIONS |
Prescription Drug
Buy-Up Option |
Not Available
|
| Alcohol Dependency Treatment Option |
This optional benefit is available at an additional
cost.
It is limited to $4,500 in any 24 consecutive months.
|
|
† Deductible waived.
3 $5,000 deductible has a 0% coinsurance. $2,500 or $3,500
deductible has a 20% coinsurance.
6 Family coinsurance maximum is 2x the Individual.
* Family deductible applies when an individual
and a spouse or one (1) or more dependents are enrolled. Therefore, prior
to benefits being paid, the entire family deductible must be met.
Note: Member is responsible for non-preferred provider charges abobe the
LifeWise negotiated amounts.
|
Plan Updates 
