|
Asuris Northwest Health - Online
Application
Index | Exclusions
& Limitations | Provider
Directory | Download Application
Benefit Schedules:
Preferred Catastrophic | Clarity
50 | Clarity 70 | Clarity
80 | HSA | HSA Comprehensive
Rate Schedules:
Preferred Catastrophic | Clarity 50 | Clarity
70 | Clarity 80 | HSA | HSA Comprehensive
ASURIS Clarity
80
(A PREFERRED PLAN)
For medically necessary services rendered
by a Preferred Plan, participating or recognized provider, the benefits of this
plan will be provided at the percentage of the allowed amount specified below
after the deductible has been met. Unless otherwised specified, all benefits
are subject to the annual deductible in addition to any copays and coinsurance.
When you have reached the annual out-of-pocket coinsurance maximum, this plan
will provide benefits at 100% of the allowed amount for the remainder of the
calendar year for the services of Preferred Plan providers only, unless otherwise
specified. The annual deductible, copays, outpatient rehabilitative care, and
most participating provider services do not apply to the annual out-of-pocket
coinsurance amount.
|
Benefits
|
Preferred Plan
Provider
|
Participating
Provider
|
|
Annual Deductible
Copays do not count toward the deductible.
Family deductible is met when three or more covered
family members incur the equivalent of three individual deductible amounts
in a calendar year
|
$500 per individual/$1,500 per family
or
$1,500 per individual/$4,500 per family
|
|
Lifetime maximum:
|
$2,000,000 per individual
|
|
Annual Out-of-Pocket Coinsurance Amount
Family out-of-pocket coinsurance amount is met
when three or more covered family members reach the equivalent of three
individual out-of-pocket coinsurance amounts in a calendar year
|
$2,500 per person
$7,500 per family
|
No out-of-pocket
maximum
|
| Professional Services |
(unless specified otherwise)
|
Office, home, and outpatient hospital visits; not subject
to deductible
|
100% after $20 per-visit copay
|
100% after $40 per-visit copay
|
Outpatient diagnostic x-ray and laboratory services;
and other professional services; subject to deductible
|
80%
|
50%
|
Coverage includes the services of physicians, osteopaths,
naturopaths, and other eligible health care professional providers
|
80%
|
50%
|
|
Hospital Facility (Inpatient & Outpatient)
Including diagnostic x-ray and laboratory
$100 copay per emergency room visit (waived if admitted)
|
80%
|
50%
|
|
Acupuncture
12 visits per calendar year maximum
|
80%
|
50%
|
|
Ambulance Services**
Ground services: $2,000 per calendar
year
|
80%
|
80%
|
|
Blood Bank**
|
80%
|
80%
|
|
Home Health and Hospice
Home Health –
130 visits per calendar year maximum
Hospice – 6 months maximum
|
80%
|
80%
|
|
Home Medical Equipment
$2,500 per calendar year maximum
|
80%
|
50%
|
|
Home Phototherapy
|
80%
|
80%
|
|
Infusion Therapy
Growth hormone only treatment is limited to $25,000
per calendar year
|
80%
|
50%
|
|
Mammography
|
80%
|
50%
|
|
Maternity
|
80%
|
50%
|
|
Occupational Injury
(provided for subscriber only)
|
same as any condition
|
|
Phenylketonuria (PKU) Formulas
Not subject to waiting periods
|
80%
|
80%
|
| Prescription Drugs |
$3,000 per calendar year maximum; not subject to
deductible***
|
Generic Formulary
|
100% after $10 Retail copay/100% after $20 Mail Order
copay
|
Brand-Name Formulary
|
70%
|
Non-Formulary
|
50%
|
|
Preventive Care
$400 per calendar year maximum; not subject to deductible.
Routine exams, immunizations, well child care, routine cancer screenings.
|
100%
|
50%
|
|
Prostheses and Orthotics
|
80%
|
50%
|
|
Rehabilitative Care
Inpatient – $4,000 per calendar year maximum
Outpatient – $2,000 per calendar year maximum
|
80%
|
50%
|
|
Skilled Nursing Facility
30 days per calendar year maximum
|
*
|
80%
|
|
Special Equipment and Supplies
|
80%
|
80%
|
|
Spinal Manipulations
10 visits per calendar year maximum
|
80%
|
50%
|
|
Transplants
$250,000 lifetime maximum; $50,000 per transplant donor
organ procurement maximum; $2,500 per transplant travel and lodging
maximum; 12-month waiting period
|
80%
|
50%
|
| Vision Care |
One routine eye exam per calendar year; not subject
to deductible
|
100% after $20 copay
|
100% after $40 copay
|
Vision hardware: $400 per calendar year maximum
|
***
|
100%
|
*At this time, these services are provided only by Participating
Providers.
**At this time, these services are provided only by Recognized
Providers.
***Prescriptions obtained from non-participating pharmacies
will not be covered except outside the service area or for cases of medical
emergency.
Cost Containment Provisions: All hospital
and skilled nursing facility admissions must be medically necessary. When outside
the service area, preadmission approval should be obtained to ensure that full
plan benefits will be provided.
Emergency Care: Emergency benefits will
be provided at the level specified for a Preferred Plan provider. In the event
of a medical emergency, treatment by a provider not normally covered under this
plan will be recognized for a 24-hour period or for such additional time as
is reasonably required to come under the care of a Preferred Plan provider.
Benefits will be based on the recognized provider’s actual charge for the service.
Copay: There is a per-visit copay for
each office call/home visit billed as such by a provider in the office, home,
or hospital outpatient department (waived for surgery, for radiation and chemotherapy,
for spinal manipulations, or if you are directly admitted to the hospital as
an inpatient). Copays do not apply toward the deductible or the out-of-pocket
coinsurance amount
Care Outside the Service Area: All care
received outside the service area, whether or not a medical emergency, will
be covered at 80% of the allowed amount, except benefits for prescription drugs
and vision hardware will be provided at the levels specified. Any balances of
charges not covered by this plan will be your responsibility.
Waiting Periods: No benefits are provided
for treatment relating to a transplant until you have been covered under this
or a prior plan with the Company (Asuris Northwest Health) for 12 consecutive
months. No benefits will be provided for preexisting conditions, including maternity,
until you have been covered under this plan for nine consecutive months, unless
you were continuously covered for at least nine months under the immediately
preceding creditable plan.
This is a brief summary of benefits, it is
not a certificate of coverage. For full coverage provisions, including a description
of waiting periods, limitations, and exclusions, refer to the plan contract.
|
Asuris
NW Health