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(Available to Washington State Residents Only) |
WiseSavings (HSA Qualified)
Summary of Benefits
All services subject to plan's deductible, unless otherwise noted.
| PCY = Per Calendar Year |
Deductible, coinsurance and copay represent WHAT YOU PAY. |
| |
Individual Plan |
Family Plan |
| MEDICAL PLAN |
Preferred Provider |
Non-Preferred Provider |
Preferred Provider |
Non-Preferred Provider |
Annual Deductible PCY (Choose one)
|
$1,880/$3,000
Per Individual |
$3,760/$6,000
Per Family* |
Coinsurance
(what you pay)
|
20% |
40% |
20% |
40% |
| Annual Coinsurance Maximum |
$2,500/$1,750 |
Unlimited |
$5,000/$3,500 |
Unlimited |
COVERED SERVICES
Annual Maximum: $2,000,000
Lifetime Maximum: Unlimited
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Office Visits including Urgent Care & Naturopathy |
Deductible,
then 20% |
Deductible,
then 40% |
Deductible,
then 20% |
Deductible,
then 40% |
|
Preventive Care Exams |
Covered in Full** |
Not Covered |
Covered in Full** |
Not Covered |
Preventative Screenings
A full list of preventive screenings, tests and services is available on lifewisewa.com |
Covered in Full** |
Deductible,
then 40% |
Covered in Full** |
Deductible,
then 40% |
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Immunizations |
Covered in Full** |
Not Covered |
Covered in Full** |
Not Covered |
| Pharmacy - Retail |
Not Covered
Pharmacy discount program*** available |
Not Covered
Pharmacy discount program*** available |
| Pharmacy - Mail Service |
| Outpatient Diagnostic Imaging & Lab Services |
Deductible
then 20% |
Deductible
then 40% |
Deductible
then 20% |
Deductible
then 40% |
| Mammography |
Covered in Full** |
DEDUCTIBLE WAIVED
then 20% |
| Emergency Room Care |
Deductible
then 20% |
Deductible
then 20%**** |
Deductible
then 20% |
Deductible
then 20%**** |
Ambulance Transportation
Air:
unlimited;
Ground: $5,000 PCY limit |
Outpatient & Inpatient
Facility Care |
Deductible
then 20% |
Deductible
then 40% |
Deductible
then 20% |
Deductible
then 40% |
Rehabilitation (Outpatient: 15 visits PCY;
Inpatient: 10 days PCY) Physical, Occupational, Massage and Speech Therapy; Cardiac &
Pulmonary Rehabilitation |
Durable Medical Equipment & Prosthetics
($5,000 PCY) |
Spinal & Other Manipulations
(12 visits PCY) |
Deductible
then 20% |
Deductible
then 40% |
Deductible
then 20% |
Deductible
then 40% |
Acupuncture
(12 visits PCY) |
Home Health Care
(120 visits
PCY) |
Deductible
then 20% |
Deductible
then 40% |
Deductible
then 20% |
Deductible
then 40% |
| Skilled Nursing Facility (20 days
PCY) Includes room & board, ancillaries & professional fees |
Hospice Care
(Inpatient: 10 days PCY; Respite: 240 hours PCY) |
| Maternity Care |
Not Covered |
Not Covered |
| Vision Care - Routine Exam |
Not Covered |
Not Covered |
| Vision Care - Hardware |
| Mental Health - Outpatient Office Visit |
Deductible
then 20% |
Deductible
then 40% |
Deductible
then 20% |
Deductible
then 40% |
| Mental Health - Inpatient Facility Care |
Transplants
(12-month waiting period; $350,000 lifetime benefit)
Organ & Bone Marrow |
Deductible
then 20% |
Not Covered |
Deductible
then 20% |
Not Covered |
* Family = Individual + one or more family members. Services for all family members covered under the same HSA-qualified plan are applied to the family deductible. The family deductible must be met before services are covered for any enrolled family member.
** Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance.
*** In order to validated current eligibility for this discount, the pharmacy will transmit your information to LifeWise Health Plan of Washington, including the details of the prescriptions to be filled. The information may also be used for other proper purposes.
**** 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.”
LifeWise Dental CoPay Plan Summary of Benefits - Optional Ad-On Benefit
(Optional benefits that are not elected are excluded from coverage)
Here are a few examples of common services this plan covers when you choose a preferred provider:
| PCY = Per Calendar Year |
Coinsurance and copay represent WHAT YOU PAY. |
| COMMONLY USED COVERED SERVICES |
PREFERRED PROVIDER |
NON-PREFERRED PROVIDER |
| Annual Deductible PCY |
Individual: $50 / $75
Family: $150 / $225 |
Benefit Maximum
per person, PCY |
$1,000 |
DIAGNOSTIC & PREVENTIVE
(no deductible applies) |
$50 or $75 deductible plan |
$50 deductible plan |
$75 deductible plan |
| Oral Exams limited to 2 PCY |
$0 |
20% |
30% |
| Bitewing X-rays |
$0 |
20% |
30% |
| Cleanings Limited to 2 PCY |
$20 |
20% |
30% |
| Flouride Treatments limited to 2 applications PCY for members under the age of 20 |
$0 |
20% |
30% |
| Sealants limited to permanent teeth; for members under age 19 |
$0 |
20% |
30% |
| BASIC (deductible applies first) |
$50 or $75 deductible plan |
$50 deductible plan |
$75 deductible plan |
| Emergency Palliative Treatment |
$5 |
40% |
50% |
| Filings one surface, amalgam; primary or permanent; limited to once per tooth surface every 24 consecutive months |
$30 |
40% |
50% |
| Periodontal Maintenance limited to 4 visits per calendar year |
$40 |
40% |
50% |
| Recementing of Crowns |
$20 |
40% |
50% |
| Crown Repair |
$25 |
40% |
50% |
| Simple Extractions erupted tooth or exposed root |
$30 |
40% |
50% |
| Space Maintainers fixed, unilateral; for members under age 20 |
$65 |
40% |
50% |
| MAJOR (12 month waiting period; deductible applies first) |
$50 or $75 deductible plan |
$50 deductible plan |
$75 deductible plan |
| Crowns, Onlays, Dentures, Partials and Bridges |
Copays vary based on the tooth location and type of material used.
Visit lifewisewa.com/dental for a complete list of covered services and copays for more information. |
60% |
70% |
| Endodontic (Root Canal) Treatment limited to 2 per arch when performed in conjunction with overdentures |
anterior tooth: $385
molar tooth: $515
bicuspid tooth: $435 |
60% |
70% |
| General Anesthesia for first 30 minutes; limited to covered dental procedures at a dental-care provider’s office when dentally necessary |
$165 |
60% |
70% |
| Oral Surgery for surgical removal of residual tooth roots |
$115 |
60% |
70% |
| Periodontal Scaling one to three teeth; limited to 2 every 12 consecutive months |
$60 |
60% |
70% |
| Periodontal Surgery osseous surgery; one to three contiguous teeth; limited to 2 every 12 consecutive months |
$350 |
60% |
70% |
Click here to view the full list of Covered Services and CoPay Schedule.
* If you visit a non-preferred provider, you'll pay the applicable non-preferred coinsurance based on the type of service provided.
You'll also be responsible for amounts charged in excess of the allowable charge. Visit lifewisewa.com/dental for details on non-preferred provider coverage.
This is 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.
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.
Copyright© 1998-2011, Maddock & Associates | Privacy Statement
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