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(Available to Washington State Residents Only) |
WiseEssentials Copay Summary of Benefits
All services subject to plan's deductible, unless otherwise noted.
| PCY = Per Calendar Year |
Coinsurance and copay represent WHAT YOU PAY. |
| MEDICAL PLAN |
Preferred Provider |
Non-Preferred Provider |
Annual Deductible
PCY (choose
one; no family deductible)
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$5,000/$7,500 |
$10,000/$15,000 |
| Coinsurance (what you
pay) |
25% |
50% |
Annual Coinsurance Maximum
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$5,000 |
Unlimited |
COVERED SERVICES
Lifetime maximum $2 million
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Office Visits including Urgent Care & Naturopathy |
DEDUCTIBLE WAIVED
on first 3 visits PCY you pay $25 copay only; additional visits subject to deductible, then 25% |
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 |
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 25% |
Deductible,
then 50% |
| Mammography |
DEDUCTIBLE WAIVED
then 25% |
Emergency Room Care
Copay waived if direct admit to an inpatient facility |
$100 copay, then subject to deductible, then 25% |
$100 copay, then subject to deductible, then 25%*** |
Ambulance Transportation
Air:
unlimited;
Ground: $5,000 PCY limit |
Deductible,
then 25% |
Deductible,
then 25%*** |
Outpatient & Inpatient
Facility Care |
Deductible,
then 25% |
Deductible,
then 50% |
Rehabilitation (Outpatient: 20 visits PCY;
Inpatient: 8 days PCY) Physical, Occupational, Massage & Speech Therapy; Cardiac &
Pulmonary Rehabilitation |
| Durable Medical Equipment & Prosthetics |
Not Covered |
Not Covered |
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 25% |
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 |
Not Covered |
Not Covered |
| Vision Care - Routine Exam |
Not Covered |
Not Covered |
| Vision Care - Hardware |
| Mental Health - Outpatient Office Visit (6 visits PCY) |
DEDUCTIBLE WAIVED
then 25% |
Deductible,
then 50% |
| Mental Health - Inpatient Facility Care (6 days PCY) |
Deductible,
then 25% |
Transplants
(12-month waiting period; $350,000 lifetime benefit) Organ & Bone Marrow |
Deductible,
then 25% |
Not Covered |
* Benefits provided at 100% of allowable charges; not subject to deductible
or coinsurance.
** In order to validate current eligibility for this discount, the pharmacy will transmit
your information to LifeWise Health Plan of Washington, including the details of
the prescription 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.”
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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