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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. |
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Individual Plan |
Family Plan |
| MEDICAL PLAN |
Preferred Provider |
Non-Preferred Provider |
Preferred Provider |
Non-Preferred Provider |
Annual Deductible PCY (Choose one)
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$1,820/$3,000
Per Individual |
$3,640/$6,000
Per Family* |
Coinsurance
(what you pay)
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20% |
40% |
20% |
40% |
| Annual Coinsurance Maximum |
$2,500/$1,750 |
Unlimited |
$5,000/$3,500 |
Unlimited |
COVERED SERVICES
Lifetime maximum $2 million
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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 ($300 PCY limit)
Routine medical exam, sports physical & women's health/well baby exams |
Covered in Full** |
Not Covered |
Covered in Full** |
Not Covered |
Preventative Screenings
PAP smear, PSA testing, colorectal cancer screening, cholesterol screening & bone density test |
Deductible,
then 20% |
Deductible,
then 40% |
Deductible,
then 20% |
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 |
DEDUCTIBLE WAIVED
then 20% |
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 (6 visits PCY) |
Deductible
then 20% |
Deductible
then 40% |
Deductible
then 20% |
Deductible
then 40% |
| Mental Health - Inpatient Facility Care (6 days PCY) |
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.”
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.
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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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