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Asuris NW Health

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PPO (Preferred) Catastrophic Benefits
$1,500 Deductible

This plan does not require you to choose a PCP when you enroll. As long as you are treated by a PPO provider when you receive medical care, you'll receive the higher Preferred benefit (80%).

Click here to find if your doctor or practitioner belongs to the "Preferred" network.

Click here for Important Information About This Benefit Summary.

Preferred Catastrophic Plan
For medically necessary services rendered by a Preferred Plan, participating or recognized provider in the service area, the benefits of this plan will be provided at the percentage of the allowed amount specified below after the deductible has been met. All benefits are subject to the annual deductible (unless noted) in addition to any copays and coinsurance. When you have reached the annual out-of-pocket coinsurance maximum for Preferred Plan or out-of-area provider services only, this plan will provide benefits at 100% of the allowed amount for Preferred Plan or out-of-area provider services for the remainder of the calendar year, unless otherwise specified. Coinsurance amounts on Preferred Plan and out-of-area provider services apply toward the out-of-pocket maximum, unless otherwise specified. The annual deductible, copays, outpatient rehabilitative care, smoking cessation program, and most services provided by participating or recognized providers do not apply to the annual out-of-pocket amount. Any balances of charges not covered by this plan will be your responsibility to pay.

Benefits	Asuris Northwest Health Preferred (PPO) Catastrophic Plan
	Preferred Plan Provider	Participating/ Recognized Provider**
Annual Deductible (per calendar year) 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	$1,500 per individual $4,500 per family
Lifetime Maximum	$1,000,000 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 "per person" out-of-pocket coinsurance amount in a calendar year, not including the deductible	$3,000 per person $9,000 per family	No out-of-pocket maximum
Professional Services Including diagnostic x-ray and laboratory. Coverage includes the services of physicians, osteopaths, naturopaths and other eligible health care professional providers.	80% (unless specified otherwise)	50% (unless specified otherwise)
Hospital Facility (Inpatient & Outpatient) Including diagnostic x-ray and laboratory. $100 copay per emergency room visit (waived if admitted)**	80%	50%
Acupuncture Services 12 visits per calendar year maximum	80%	50%
Ambulance Services Ground services: $2,000 per calendar year Air ambulance must be approved by Asuris Northwest Health	80%*
Blood Bank	80%

Benefits	Asuris Northwest Health Preferred (PPO) Catastrophic Plan
	Preferred Plan Provider	Participating/ Recognized Provider**
Home Health and Hospice Home Health - 130 visits per calendar year maximum Hospice - 6 months maximum	80%*
Home Medical Equipment $2,500 per calendar year maximum	80%	50%
Home Phototherapy	80%*
Infusion Therapy Growth hormone treatment is limited to $25,000 per calendar year	80%	50%
Mammography	80%	50%
Maternity	Not covered
Prescription Drugs	Not covered
Preventive Care	Not covered
Prostheses and Orthotics	80%	50%
Rehabilitation 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%*
Smoking Cessation** $500 lifetime maximum	80%

Benefits	Asuris Northwest Health Preferred (PPO) Catastrophic Plan
	Preferred Plan Provider	Participating/ Recognized Provider**
Special Equipment and Supplies	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%	see contract
Vision Care - Eye Exam	Not covered
Vision Care - Hardware	Not covered

* At this time, these services are provided only by Participating/Recognized Providers.

** Benefits do not apply to the out-of-pocket coinsurance amount.

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: In the event of a medical emergency inside the service area, benefits will be provided at the level specified for a Preferred Plan provider. Benefits for recognized providers will be based on the recognized provider's actual charge for the service. Outside the service area, benefits will be provided at the level specified below.

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. Any balance 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 Asuris Northwest Health or its parent company for 12 consecutive months. No benefits will be provided for preexisting conditions 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.

Important Information About This Benefit Summary

This is a brief summary of benefits; it is not a contract or a certificate of coverage. The complete terms of coverage are determined by the carrier's contract. While we have accurately represented the information in this Benefit Summary as of the time it was published, should any discrepancies exist between this Benefit Summary and the carrier's contract, the carrier's contract shall prevail. Please refer to the carrier's contract for a complete statement of benefits including waiting periods, limitations and exclusions.

Washington State Health, Dental, Life and Disability Insurance	206.442.1111 or 1.866.369.6700