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Comprehensive Plan Benefits
 Preferred80 and Choice80; Preferred70 and Choice70
 $500 or $1,000 Deductible

Preferred80 and Choice80 plan benefits are exactly the same, as are the benefits of the Preferred70 and Choice70 plans. The difference between the plans is the network of medical providers you can use to receive the highest benefit. Preferred80 and Preferred70 are PPO (Preferred) plans. Choice80 and Choice70 are traditional (Participating) plans. LifeWise PPO plans are the most popular because they are about 7% less expensive than LifeWise traditional plans, yet still allow you to be treated by about 90% of medical providers to receive the highest benefit. Chances are excellent that your doctor is a LifeWise PPO plan provider. Click here to see if your doctor or practitioner belongs to the "Preferred" or "Participating" network.

All four plans cover prescription drugs, maternity, preventive care and vision care expenses.

Click here for Important Information About This Benefit Summary.
 
Benefits

LifeWise Health Plan
Preferred80 or Choice80

LifeWise Health Plan
Preferred70 or Choice70
Preferred (Preferred80) or Participating (Choice80) Providers Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers Preferred (Preferred80) or Participating (Choice80) Providers Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers
Annual Deductible
 Your choice of two amounts

$500 or $1,000 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

$2,000
After the out-of-pocket maximum is met, Preferred (Preferred80) or Participating (Choice80) Providers are covered at 100%)

No annual out-of-pocket maximum for services provided by Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers*

$3,000
After the out-of-pocket maximum is met, Preferred (Preferred80) or Participating (Choice80) Providers are covered at 100%)

No annual out-of-pocket maximum for services provided by Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers*
Preventive Care
 Routine physicals; related diagnostic
x-ray & lab; well-baby care and immunizations

100% up to $300 maximum per calendar year (deductible waived)

 Not covered 100% up to $200 maximum per calendar year (deductible waived) Not covered
Professional Services
 Office visits, hospital physician visits, surgeon, anesthesia, etc.		 80% 50% of allowable charges 70% 50% of allowable charges
X-Ray & Laboratory Services
 Including mammogram (or see Exclusions)		 80% 50% of allowable charges 70% 50% of allowable charges

Benefits

LifeWise Health Plan
Preferred80 or Choice80

LifeWise Health Plan
Preferred70 or Choice70
Preferred (Preferred80) or Participating (Choice80) Providers Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers Preferred (Preferred80) or Participating (Choice80) Providers Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers
Hospital Inpatient/Outpatient 80% 50% of allowable charges 70% 50% of allowable charges
3-Tier Prescription Drug Benefit
Separate annual deductible applies; prescriptions limited to 34-day supply; $5,000 maximum per calendar year		 After $200 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)		 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
One routine eye exam every 24 months		 100% (deductible waived)* 100% of allowable charges (deductible waived)* 100% (deductible waived)* 100% of allowable charges (deductible waived)*
Vision Care
Corrective hardware		 $200 for frames and lenses or contact lenses*
Maternity Care
 Including prenatal care		 80% 50% of allowable charges 70% 50% of allowable charges
Emergency Services
 Worldwide coverage		 80%; $100 copay per emergency room visit (emergency room copay waived if admitted) 70%; $100 copay per emergency room visit (emergency room copay waived if admitted)
Ambulance Transportation 80%; limited to $5,000 per calendar year 70%; limited to $5,000 per calendar year

Benefits

LifeWise Health Plan
Preferred80 or Choice80

LifeWise Health Plan
Preferred70 or Choice70
Preferred (Preferred80) or Participating (Choice80) Providers Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers Preferred (Preferred80) or Participating (Choice80) Providers Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers
Rehabilitation
 $5,000 annual maximum for inpatient & outpatient combined; $2,500 or $1,000 annual maximum for outpatient (Preferred 80 or Preferred70, respectively)		 80% 50% of allowable charges 70% 50% of allowable charges
Home Medical Equipment
Including prosthetics & supplies; $5,000 maximum per calendar year		 80% 50% of allowable charges 70% 50% of allowable charges
Skilled Nursing Facility
Limited to $20,000 or $10,000 per calendar year (Preferred80 or Preferred70, respectively)		 80% 50% of allowable charges 70% 50% of allowable charges
Home Health and Hospice
Home health care limited to 130 visits per calendar year; hospice limited to 6 months per calendar year		 80% 50% of allowable charges 70% 50% of allowable charges
Transplants
$250,000 lifetime maximum;
12-month waiting period		 80% 50% of allowable charges 70% 50% of allowable charges

Benefits

LifeWise Health Plan
Preferred80 or Choice80

LifeWise Health Plan
Preferred70 or Choice70
Preferred (Preferred80) or Participating (Choice80) Providers Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers Preferred (Preferred80) or Participating (Choice80) Providers Non-Preferred (Preferred80) or Non-Participating (Choice80) Providers
Acupuncture Services
Limited to 12 visits per calendar year		 80% 50% of allowable charges 70% 50% of allowable charges
Chiropractic/Osteopathic & Other Spinal Manipulations
Limited to 12 visits per calendar year		 80% 50% of allowable charges 70% 50% of allowable charges
Naturopathic Services 80% 50% of allowable charges 70% 50% of allowable charges
Massage Therapy
Subject to outpatient rehabilitation maximum		 80% 50% of allowable charges 70% 50% of allowable charges
Dietitians/Nutritionists 80% 50% of allowable charges 70% 50% of allowable charges

* these services do not apply toward the annual out-of-pocket maximum

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.

   

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