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.”
| |
WiseEssentials |
| |
Preferred Providers |
Non-Preferred & extended providers |
Annual Deductible PCY (choose one)
(Family is 3x the individual deductible)* |
Individual: $1,500 / $2,500 /
$5,000 / $7,500 / $10,000 |
2x individual deductible |
| Coinsurance1 (what you pay) |
25% |
50% |
Annual Coinsurance Maximum
(family = 2x individual)2 |
$9,000 |
Unlimited |
| 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)3 |
DEDUCTIBLE WAIVED you pay
$25 on first 6 visits; additional visits
subject to deductible then 25% |
Deductible, then 50% |
Preventive Screenings
(includes Pap smear, PSA
testing, home colon cancer screening, cholesterol
screening and bone density test) |
Covered in full4 |
| Immunizations |
| Professional Care
|
| Office Visit including Urgent Care2 |
DEDUCTIBLE WAIVED you pay
$25 on first 6 visits; additional visits
subject to deductible then 25% |
Deductible, then 50% |
| Other Outpatient and Inpatient Professional Services |
Deductible, then 25% |
| Alternative Care
|
Chiropractic
12 visits PCY
(visits
shared with Acupuncture) |
$25 Copay per visit |
Deductible, then 50% |
Acupuncture
12 visits PCY
(visits shared with Chiropractic) |
| Naturopathy3 |
DEDUCTIBLE WAIVED you pay
$25 on first 6 visits; additional visits
subject to deductible then 25% |
| Diagnostic Services
|
| Outpatient Diagnostic Imaging and Lab Services |
Deductible, then 25%
($1,500 Deductible Plan: no deductible applies) |
Deductible, then 50% |
| Mammography |
Covered in full4 |
| Pharmacy
|
| Retail Pharmacy (30-day supply) |
$20 Generics only |
Not covered |
| Mail Service Pharmacy (90-day supply) |
$50 Generics only |
| Emergency Care
|
| Emergency Room Care (copay waived if direct admit to an inpatient facility) |
$100 Copay, then subject to deductible, then 25% |
| Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit) |
Deductible, then 25% |
| Facility Care
|
| Inpatient Facility Care |
Deductible, then 25% |
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 50% |
| Vision Care
|
| Routine Vision Exam |
Not Covered |
| Vision Hardware |
| Other Services
|
| Supplies, Equipment and Prosthetics $5,000 PCY |
Deductible, then 25% |
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
* Family = Individual plus one or more family members
1 All coinsurance amounts are the member’s percentage of maximum allowable amounts after deductible
2 Does not include deductible
3 Office visits, preventive exams and
naturopathy are shared
4 Benefits provided at 100% of maximum allowable amounts; not subject to deductible or coinsurance
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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