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(Available to Washington State Residents Only) |
WiseChoices Prime - Summary of Benefits
All services subject to plan's deductible, unless otherwise noted. Coinsurance is 30%.
| PCY = Per Calendar Year |
Coinsurance and copay represent WHAT YOU PAY. |
| MEDICAL PLAN |
Preferred Provider |
Non-Preferred Provider |
Annual Deductible
PCY (choose
one)
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Individual: $1,500/$3,000
Family: $4,500/$9,000 |
Individual: $3,000/$6,000
Family: $9,000/$18,000 |
Coinsurance
(what you
pay) |
30% |
50% |
Annual Coinsurance Maximum
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$6,500 Individual or
Family = 3x Individual |
Unlimited |
COVERED SERVICES
Lifetime maximum $2 million
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Office Visits including Urgent Care & Naturopathy |
DEDUCTIBLE WAIVED
$30 Copay |
Deductible,
then 50% |
Preventive Care Exams
Routine medical exam, sports physical & women's health/well baby exams |
Preventative Screenings
PAP smear, PSA testing, colorectal colon cancer screening, cholesterol screening & bone density test |
Covered in Full* |
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Immunizations |
Not Covered |
Pharmacy - Retail
(30-day supply) Brand: $3,000 PCY limit; Generic: Unlimited |
$10/30%/50%/30% |
Not Covered |
Pharmacy - Mail Order
(90-day supply) Brand: $3,000 PCY limit; Generic: Unlimited |
$25/25%/45%/30% |
| Outpatient Diagnostic Imaging & Lab Services |
Deductible,
then 30% |
Deductible,
then 50% |
| Mammography |
DEDUCTIBLE WAIVED
then 30% |
Emergency Room Care
Copay waived if direct admit to an inpatient facility |
$100 copay, then subject to deductible, then 30% |
$100 copay, then subject to deductible, then 30%** |
Ambulance Transportation
Air:
unlimited; Ground: $5,000 PCY limit |
Deductible,
then 30% |
Deductible,
then 30%** |
Outpatient & Inpatient
Facility Care |
Deductible,
then 50% |
Rehabilitation (Outpatient: 20 visits PCY;
Inpatient: 8 days PCY) Physical, Occupational, Massage & Speech Therapy; Cardiac &
Pulmonary Rehabilitation |
| Durable Medical Equipment & Prosthetics ($5,000 PCY) |
Spinal & Other Manipulations
(12 visits PCY) |
DEDUCTIBLE WAIVED
$25 Copay |
Deductible,
then 50% |
Acupuncture
(12 visits PCY) |
Home Health Care
(130 visits
PCY) |
Deductible,
then 30% |
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 |
Deductible,
then 30% |
Deductible,
then 50% |
Vision Care - Routine Exam
(One exam per two calendar years) |
Covered in Full |
Covered in Full |
Vision Care - Hardware
(Per two calendar years) |
$200 for frames, lenses
& contact lenses |
$200 for frames, lenses
& contact lenses |
| Mental Health - Outpatient Office Visit (6 visits PCY) |
DEDUCTIBLE WAIVED
$30 Copay |
Deductible,
then 50% |
| Mental Health - Inpatient Facility Care (6 days PCY) |
Deductible,
then 30% |
Transplants
(12-month waiting period; $350,000 lifetime benefit) Organ & Bone Marrow |
Deductible,
then 30% |
Not Covered |
* Benefits provided at 100% of allowable charges: not subjeect to deductible or coinsurance.
** Unlike services received at other non-preferred providers, this service is subject to the preferred provider deductible and coinsurance.
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.”
This is a only a summary of the major benefits provided by this plan. This is not a contract. For full coverage provisions, including a description of waiting periods, limitations, and exclusions, refer to the plan contract.
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E-mail us for more information and a free quote or CALL TOLL FREE
1-800-875-4490 (in the U.S.)
or 1-253-854-0199 (outside the U.S.)
Fax: 1-253-896-9411
Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424
Serving all of Washington at 800-875-4490, Seattle at 206-682-1628,
Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291.
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