| Annual Deductibles |
The Healthy Investor™ HSA Individual & Family |
| Individual |
$2,000 |
$3,000 |
| Family |
$4,000 |
$6,000 |
Annual Coinsurance Maximums **
(Does not include deductible, unless otherwise stated) |
| Individual |
$5,000 Par Unlimited Non-Par |
| Family |
$10,000 Par Unlimited Non-Par |
| Lifetime Maximum |
$2,000,000 |
| Non-Participating Provider Coinsurance |
50% |
Preventive Care
($350 maximum per calendar year for all preventive care) |
Not subject to deductible |
| Annual Routine Physical Exam |
80% |
Well Baby Care
(to 24 months of age) |
80% |
| Annual Routine Eye Exam |
VSP Discount Program |
| Smoking Cessation-Professional Services |
80%, $150 maximum per year |
| Outpatient Lab & X-Ray |
80% |
| Mammography and PSA - Routine |
80%, Not subject to deductible |
| Mammography and PSA - Diagnostic |
80% |
| Professional Services |
| Office, home, naturopath or urgent care visits |
80% |
| Other professional services |
80% |
Spinal & Extremity Manipulations
(12 manipulations per calendar year) |
80% |
Acupuncture
(12 treatments per calendar year) |
80% |
| Maternity |
80% |
| Facility/Hospital Services |
| Inpatient |
80% |
| Outpatient Surgery |
80% |
| Emergency Room & Supplies |
80% |
Ambulance-Ground & Air
($5,000 maximum per calendar year) |
80% |
Outpatient Rehabilitation
(Physical, Speech, Massage & Occupational Therapy) ($1,000 maximum per year) |
80% |
Home Health Care
(130 visits per calendar year) |
80% |
Hospice
(6 months per calendar year) |
80% |
Mental Health
(prior authorization required) |
|
| Inpatient |
80% |
| Outpatient |
80% |
Medical Equipment & Supplies
($2,500 maximum per calendar year) |
80% |
Skilled Nursing Facility
(in lieu of hospitalization) |
80% |
Occupational Injury
(owners and officers only) ($50,000 maximum per calendar year) |
80% |
Prescription Drugs
($3,000 maximum per calendar year, maximum does not apply for diabetes)
Tier 1: Generic
Tier 2: Preferred Brand Name
Tier 3: Non-Preferred Brand Name |
80%
80%
80% |
| Optional Programs |
Dental
(through Washington Dental Service) |
Yes |
| All benefits are subject to annual deductible and/or copay (if applicable) unless otherwise stated. This benefit comparison contains only a brief explanation of the more important coverage
features offered. It does not constitute a contract. Complete coverage details, including waiting periods and other limits and exclusions, are in the contracts. In the event of discrepancies, the
contract shall govern. *In the case of accidental injury, charges for medically necessary covered services directly related to the treatment of the injury are exempt from the deductible for a period
of up to six (6) months, provided initial treatment for the injury is received within (72*) hours of the onset of the injury. After six (6) months, the condition is considered to be chronic and charges
related to the treatment of the injury would be applied to any outstanding deductible. All other applicable benefit limitations and maximums apply. **After member satisfies the annual deductible
and coinsurance maximum, KPS pays 100% of covered benefits for the remainder of the calendar year, with some limitations. If you choose a non-participating provider, your coinsurance costs are higher.
In addition, it is your responsibility to pay the difference between any amounts billed by the non-participating provider or facility and the amount paid by KPS. Please refer to our website, www.kpshealthplans.com,
to find a participating provider. +The Healthy Investor TM family plans are designed for two or more family members. The entire family deductible must be satisfied before benefits are paid, annual
routine physical exams, well-baby exams, routine mammograms, and routine prostate cancer screening are not subject to the annual deductible. |
Asuris NW Health 
