|
Benefits |
LifeWise Health Plan
Share MSA |
|
Preferred Provider |
Non-Preferred Provider |
Annual Deductible
Your
choice of two amounts, per calendar year |
$1,700 or $2,500 per
individual;
or
$3,400 or $5,000 per
family |
|
Lifetime Maximum |
$2,000,000 per individual |
Annual Out-of-Pocket Maximum
Per
calendar year;
deductible included;
after the out-of-pocket maximum is met, Preferred Providers are
covered at 100% for the remainder of the calendar year |
$3,300 per
individual; or
$6,050 per family |
No annual out-of-pocket maximum for services provided by Non-Preferred
Providers* |
|
Preventive Care |
Not covered |
Professional Services
Office visits, hospital physician visits, surgeon, anesthesia, etc. |
80% |
60% of allowable
charges |
X-Ray & Laboratory Services
Including
mammogram |
80% |
60% of allowable
charges |
|
Hospital Inpatient/Outpatient |
80% |
60% of allowable
charges |
|
 |
|
Benefits |
LifeWise Health Plan
Share MSA |
|
Preferred Provider |
Non-Preferred Provider |
|
Prescription Drug Benefit |
Not covered |
|
Vision Care |
Not covered |
|
Maternity Care |
Not covered |
Emergency Services
Worldwide coverage |
80% |
|
Ambulance Transportation |
80%; limited to
$5,000 per calendar year |
Rehabilitation
Including
Massage Therapy, $5,000 annual
maximum for inpatient & outpatient combined; $1,000 annual maximum for
outpatient |
80% |
60% of allowable
charges |
Home Medical Equipment
Including
prosthetics & supplies; $5,000 maximum per calendar year |
80% |
60% of allowable
charges |
Skilled Nursing Facility
Limited
to $10,000 per calendar year |
80% |
60% of allowable
charges |
|
|
|
Benefits |
LifeWise Health Plan
Share MSA |
|
Preferred Provider |
Non-Preferred Provider |
Home Health and Hospice
Home
health care limited to 130 visits per calendar year; hospice limited
to 6 months per calendar year |
80% |
60% of allowable
charges |
Transplants
$250,000
lifetime maximum;
12-month waiting period |
80% |
60% of allowable
charges |
Acupuncture Services
Limited
to 12 visits per calendar year |
80% |
60% of allowable
charges |
Chiropractic/Osteopathic & Other Spinal Manipulations
Limited to
12 visits per calendar year |
80% |
60% of allowable
charges |
|
Naturopathic Services |
80% |
60% of allowable
charges |
Massage Therapy
Subject to
outpatient rehabilitation maximum |
80% |
60% of allowable
charges |
|
Dietitians/Nutritionists |
80% |
60% of allowable
charges |
