| |
WiseChoices Prime Benefits |
| PCY = Per Calendar Year |
Preferred |
Non-Preferred |
| Annual Deductible PCY (choose
one) |
Individual: $1,500 / $3,000
Family: $4,500 / $9,000 |
Individual: $3,000 / $6,000
Family: $9,000 / $18,000 |
| Coinsurance (what you pay) |
30% |
50% |
| Annual Coinsurance Maximum |
$6,500 Indiv. or
Family = 3x Indiv. |
Unlimited |
| Covered Services (Lifetime maximum $2 million) |
| Office Visits and Urgent Care & Naturopathy |
DEDUCTIBLE WAIVED
$30 Copay |
Deductible, then 50% |
| Preventive Exams (routine medical exam,
sports
physical & women’s health/well baby exams) |
| Preventive Screenings (Pap smear, PSA
testing,
colorectal cancer screening, cholesterol screening &
bone density test.) |
Covered in Full* |
| Immunizations |
Not Covered |
Pharmacy - Retail
(Generics: Unlimited; Brand: $3,000 PCY limit)
(30 day supply) |
$10 / 30% / 50% / 30% |
Not Covered |
Pharmacy - Mail Service
(Generics: Unlimited; Brand: $3,000 PCY limit)
(90 day supply) |
$25 / 25% / 45% / 30% |
Not Covered |
| Outpatient Diagnostic X-rays and Lab Services |
Deductible, then 30% |
Deductible, then 50% |
| Mammography |
Deductible waived
then 30% |
| Emergency Room Care - Copay waived if direct admit to an inpatient facility |
$100 copay, then subject to deductible, then 30% |
$100 copay, then subject to deductible, then 30%** |
| Ambulance Transportation - Air: unlimited; Ground: $5,000 PCY limit |
Deductible, then 30% |
Deductible, then 30%** |
| Inpatient & Outpatient Facility Care |
Deductible, then 30% |
Deductible, then 50% |
| Rehabilitation (Outpatient: 20 days PCY; Inpatient: 8 days PCY) Physical, occupational, massage & speech therapy; cardiac &
pulmonary rehabilitation |
| Durable Medical Equipment and Prosthetics - ($5,000 PCY) |
| Spinal and Other Manipulations (12 visits PCY) |
Deductible waived
$25 Copay |
Deductible, then 50% |
| Acupuncture (12 visits PCY) |
| Home Health Care (130 visits PCY) |
Deductible, then 30% |
Deductible, then 50% |
Skilled Nursing Facility (45 days PCY)
Includes room and board, ancillaries & professional fees |
| Hospice Care (Inpatient: 10 days PCY; Respite: 240 hours PCY) |
| Maternity Care |
Deductible, then 30% |
Deductible, then 50% |
| Vision - Routine Exam (One exam per two calendar years) |
Covered in Full |
Covered in Full |
| Vision - Hardware (Per two calendar years) |
$200 for frames, lenses
& contact lenses |
$200 for frames, lenses
& contact lenses |
| Mental Health–Outpatient Office Visit |
Deductible waived
$30 Copay |
Deductible, then 50% |
| Mental Health–Inpatient Facility Care |
Deductible, then 30% |
| Transplants (12-month waiting period; $350,000 lifetime benefit)
Organ & bone marrow |
Deductible, then 30% |
Not Covered |
* Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance.
** Unlike services received at other non-preferred providers, this service
is subject to the preferred provider deductible and coinsurance.
Note: Deductible, coinsurance and copay represent what you pay.
Benefits apply after calendar year deductible is met, unless otherwise noted as “Deductible Waived,” “Copay” or “Covered in Full.”
All coinsurance amounts are based on allowable charges. Balance billing
may apply if a provider is not contracted with LifeWise Health Plan of Washington.
Please note that this is a general summary. Your individual health plan
contract will describe the actual terms, conditions and exclusions of coverage. |
Assurant Health
