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WiseSavings HSA
Premiums | WiseSavings
HSA Benefits
LifeWise WiseSavings HSA Benefits
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WiseSavings (Individual) |
WiseSavings (Family) |
| PCY = Per Calendar Year |
Preferred |
Non-Preferred |
Preferred |
Non-Preferred |
| Annual Deductible PCY (choose
one) |
$1,820/$3,000
Per Individual
|
$3,640/$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 (Lifetime maximum $2 million) |
| Office Visits and Urgent Care & Naturopathy |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 20% |
Deductible, then 40% |
| Preventive Exams (routine medical exam,
sports
physical & womens health/well baby exams) |
Covered in Full** |
Not covered |
Covered in Full** |
Not covered |
| Preventive 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% |
| Immunizations |
Covered in Full** |
Not covered |
Covered in Full** |
Not covered |
| Pharmacy - Retail |
Not covered.
Discount Program available.*** |
Not covered.
Discount Program available.*** |
| Pharmacy - Mail Service |
| Outpatient Diagnostic X-rays and 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 |
| Inpatient & Outpatient 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 & speech therapy; cardiac &
pulmonary rehabilitation |
| Durable Medical Equipment and Prosthetics - ($5,000 PCY) |
| Spinal and 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 and board, ancillaries & professional fees |
| Hospice Care (Inpatient: 10 days PCY; Respite: 240 hours PCY) |
| Maternity Care |
Not Covered |
Not Covered |
| Vision - Routine Exam |
Not Covered |
Not Covered |
| Vision - 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 members.
** 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.
Note: 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.”
All coinsurance amounts are based on allowable charges. Balance billing
may apply if a provider is not contracted with LifeWise Health Plan of Washington.
Please note that this is a general summary. Your individual health plan
contract will describe the actual terms, conditions and exclusions of coverage. |
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