| |
WiseEssentials Rx Benefits |
| PCY = Per Calendar Year |
Preferred |
Non-Preferred |
| Annual Deductible PCY (choose
one) |
$1,850/$,2,500/$3,500 |
$3,700/$5,000/$7,000 |
| 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
6 visits subject to 25%;
subsequent visits subject to
deductible and 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
(30 day supply & $3,000 PCY limit) |
Generics only Retail: $15 |
Not Covered |
Pharmacy - Mail Service
(90 day supply & $3,000 PCY limit) |
Generics only Mail Order: $40 |
Not Covered |
| Outpatient Diagnostic X-rays and Lab Services |
Deductible waived
then 25% for $1,850 deductible plan only |
Deductible, then 50% |
Deductible, then 25% for all others |
| 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 - ($5,000 PCY) |
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
then 25% |
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.
** 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
