|
Benefits |
LifeWise Health Plan
Share Preferred or Share Traditional |
| |
Preferred (Share
Preferred) or Participating (Share Traditional) Providers |
Non-Preferred (Share
Preferred) or Non-Participating (Share Traditional) Providers |
Annual Deductible
Your
choice of three amounts |
$2,500, $5,000 or $10,000 per individual, per calendar year |
|
Lifetime Maximum |
$2,000,000 per individual |
Annual Out-of-Pocket Maximum
Per
individual, per calendar year; deductible not included |
$6,000
After the out-of-pocket maximum is met, Preferred (Share Preferred) or
Participating (Share Traditional) Providers are covered at 100% |
No annual out-of-pocket maximum for services provided by Non-Preferred
(Share Preferred) or Non-Participating (Share Traditional) Providers* |
Preventive Care
Routine physicals; related diagnostic
x-ray & lab; well-baby care and immunizations |
Not covered |
Professional Services
Office visits, hospital physician visits, surgeon, anesthesia, etc. |
70% |
50% of allowable
charges |
X-Ray & Laboratory Services
Including
mammogram (or see Exclusions) |
70% |
50% of allowable
charges |
|
Hospital Inpatient/Outpatient |
70% |
50% of allowable
charges |
|
 |
|
Benefits |
LifeWise Health Plan
Share Preferred or Share Traditional |
|
Preferred (Share
Preferred) or Participating (Share Traditional) Providers |
Non-Preferred (Share
Preferred) or Non-Participating (Share Traditional) Providers |
3-Tier Prescription Drug Benefit
Separate
annual deductible applies; prescriptions limited to 34-day supply;
$5,000 maximum per calendar year |
After $500 prescription drug deductible,
member pays:
Tier 1 = 20% (generic drugs)
Tier 2 = 30% (preferred brand name drugs)
Tier 3 = 50% (non-preferred brand name drugs) |
|
Vision Care |
Not covered |
Maternity Care
Including
prenatal care |
Not covered |
Emergency Services
Worldwide coverage |
70%; $100 copay per emergency room visit
(emergency room copay waived if admitted) |
|
Ambulance Transportation |
70%; limited to $5,000 per calendar year |
Rehabilitation
$5,000 annual
maximum for inpatient & outpatient combined; $1,000 annual maximum for
outpatient |
70% |
50% of allowable
charges |
Home Medical Equipment
Including
prosthetics & supplies; $5,000 maximum per calendar year |
70% |
50% of allowable
charges |
Skilled Nursing Facility
Limited
to $10,000 per calendar year |
70% |
50% of allowable
charges |
|
|
|
Benefits |
LifeWise Health Plan
Share Preferred or Share Traditional |
|
Preferred (Share
Preferred) or Participating (Share Traditional) Providers |
Non-Preferred (Share
Preferred) or Non-Participating (Share Traditional) Providers |
Home Health and Hospice
Home
health care limited to 130 visits
per calendar year; hospice limited
to 6 months per calendar year |
70% |
50% of allowable
charges |
Transplants
$250,000
lifetime maximum;
12-month waiting period |
70% |
50% of allowable
charges |
Acupuncture Services
Limited
to 12 visits per calendar year |
70% |
50% of allowable
charges |
Chiropractic/Osteopathic & Other Spinal Manipulations
Limited to
12 visits per calendar year |
70% |
50% of allowable
charges |
|
Naturopathic Services |
70% |
50% of allowable
charges |
Massage Therapy
Subject to
outpatient rehabilitation maximum |
70% |
50% of allowable
charges |
|
Dietitians/Nutritionists |
70% |
50% of allowable
charges |
