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LifeWise WiseSavings HSA Health
Plans - 2012 Benefit Summary*
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Benefits
PCY=Per Calendar Year |
WiseSavings - Individual |
WiseSavings - Family |
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Annual
Deductible
PCY (choose one) |
$1,880 / $3,000 |
$3,760
/ $6,000
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Coinsurance
(what you pay) |
20% |
20% |
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Annual Coinsurance
Maximum
(once met, preferred
providers covered in full) |
$2,500
/ $1,750 |
$5,000
/ $3,500 |
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Out-Of-Pocket Maximum (includes
deductible & coinsurance) |
$4,380
/ $4,750 |
$8,760
/ $9,500 |
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Calendar Year Maximum
(per individual) |
2 Million |
2 Million |
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Preventive Care Exams |
Covered in full |
Covered in full |
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Immunizations |
Covered in full |
Covered in full |
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Preventive Screenings
(includes
mammograms) |
Covered in full |
Covered in full |
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Office
Visits
(including Urgent Care &
Naturopathy) |
Deductible, then 20% |
Deductible, then 20% |
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Hospital
Inpatient/Outpatient |
Deductible, then 20% |
Deductible, then
20% |
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Outpatient Diagnostic Imaging & Lab Services |
Deductible, then 20% |
Deductible, then
20% |
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Maternity Care |
Not Covered |
Not Covered |
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Emergency Services
(Worldwide coverage) |
Deductible, then 20% |
Deductible, then 20% |
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Rehabilitation
(Physical,
Occupational, Speech & Massage Therapy; Cardiac & Pulmonary
Rehabilitation) |
Deductible, then 20%
Inpatient: 10 days PCY
Outpatient: 15 visits PCY |
Deductible, then
20%
Inpatient: 10 days PCY
Outpatient: 15 visits PCY |
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Durable
Medical Equipment & Prosthetics
($5,000 PCY) |
Deductible, then 20% |
Deductible, then
20% |
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Skilled
Nursing Facility
(20 days PCY) Includes
room & board, ancillaries & professional fees |
Deductible, then 20% |
Deductible, then
20% |
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Home
Health Care
(120 visits PCY) |
Deductible, then 20% |
Deductible, then
20% |
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Hospice
Care
(Inpatient: 10 days PCY; Respite:
240 hours PCY) |
Deductible, then 20% |
Deductible, then
20% |
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Acupuncture Services
(12 visits PCY) |
Deductible, then 20% |
Deductible, then 20% |
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Spinal &
Other Manipulations (12 visits PCY) |
Deductible, then 20% |
Deductible, then 20% |
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Vision
Exam
(One routine exam per two
calendar years) |
Not
Covered |
Not
Covered |
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Vision
Hardware
(per two calendar years) |
Not
Covered |
Not
Covered |
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Mental
Health - Outpatient Office Visit |
Deductible, then 20% |
Deductible, then 20% |
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Mental
Health - Inpatient Facility Care |
Deductible, then 20% |
Deductible, then
20% |
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Pharmacy - Retail
(30-day supply)
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Not
Covered
**Pharmacy Discount program available |
Not
Covered
**Pharmacy Discount program available |
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Pharmacy - Mail Service
(90-day
supply)
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Not
Covered
**Pharmacy Discount program available |
Not
Covered
**Pharmacy Discount program available |
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Transplants
(12-month waiting period;
$250,000 lifetime benefit) Organ & Bone Marrow |
Deductible, then 20% |
Deductible, then
20% |
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24 Hour
Coverage
(when enrollee is not entitled
to receive Worker's Compensation) |
Yes |
Yes |
*This is an overview of
Preferred Provider Network
deductible, coinsurance and copay levels only. Non-Preferred Provider
deductible, coinsurance and copay levels are not shown and are higher in most
instances.
Preferred Provider Directory.
**Pharmacy discount program. Instantly save on
qualifying drugs at select retail pharmacies. Simply show your LifeWise ID
card at any
participating network pharmacy.
Compare prescription medication costs.
This is only a summary of the major benefits provided
by LifeWise. This is not a contract. See Benefit Booklet/Contract
for specific coverage information.
Questions? 800-877-8019
Copyright 2012, Green Financial, All Rights Reserved
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