| |
WiseEssentials Copay Benefits |
| PCY = Per Calendar Year |
Preferred |
Non-Preferred |
Annual Deductible PCY
(choose one; no family deductible) |
$5,000/$7,500 |
$10,000/$15,000 |
| Coinsurance (what you pay) |
25% |
50% |
| Annual Coinsurance Maximum |
$5,000 |
Unlimited |
| Covered Services (Lifetime maximum $2 million) |
| Office Visits and Urgent Care & Naturopathy |
Deductible waived on first 3 visits at $25 copay; additional visits subject to deductible, then 25% |
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 |
Not Covered |
| Pharmacy - Retail |
Not covered.
Discount Program available.** |
| Pharmacy - Mail Service |
| Outpatient Diagnostic X-rays and Lab Services |
Deductible, then 25% |
Deductible, then 50% |
| Mammography |
Deductible waived
then 25% |
| Emergency Room Care - Copay waived if direct admit to an inpatient facility |
$100 copay, then subject to deductible, then 25% |
$100 copay, then subject to deductible, then 25%*** |
| Ambulance Transportation - Air: unlimited; Ground: $5,000 PCY limit |
Deductible, then 25% |
Deductible, then 25%*** |
| Inpatient & Outpatient Facility Care |
Deductible, then 25% |
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 |
Not Covered |
Not Covered |
| 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 25% |
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 |
Not Covered |
| Vision - Routine Exam (One exam per two calendar years) |
Not Covered |
| Vision - Hardware (Per two calendar years) |
| Mental Health–Outpatient Office Visit |
Deductible waived
$25 Copay |
Deductible, then 50% |
| Mental Health–Inpatient Facility Care |
Deductible, then 25% |
| Transplants (12-month waiting period; $350,000 lifetime benefit)
Organ & bone marrow |
Deductible, then 25% |
Not Covered |
* Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance.
** In order to validate current eligibility for this discount, the pharmacy will transmit your information to LifeWise Health Plan of Washington,
including the details of the prescription to be filled. The information may also be used for other proper purposes.
*** 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
