| |
Benefits |
WiseChoices
Prime |
WiseEssentials
Rx |
WiseEssentials Copay |
WiseSimplicity |
| |
Annual
Deductible PCY (choose one) |
Individual: $1,500/$3,000
Family: $4,500/$9,000 |
$1,850, $2,500 or $3,500 |
$5,000 or $7,500 |
$10,000 |
| |
Coinsurance
(what you pay) |
30% |
25% |
25% |
0% |
| |
Annual Coinsurance
Maximum
(once met, preferred
providers covered in full) |
$6,500 Indiv. or
Family = 3X Indiv. |
$5,000 per Individual |
$5,000 per Individual |
$0 |
| |
Lifetime Maximum
(per individual) |
2 Million |
2 Million |
2 Million |
2
Million |
| |
Preventive Care Exam
(routine medical exam,
sports physical, and well baby exam) |
Deductible Waived;
$30
Copay |
Deductible waived
on first 6 visits then 25%; additional visits subject to
deductible then 25% |
Deductible waived
on first 3 visits at $25 copay; additional visits subject to deductible
then 25% |
Deductible Waived;
then 0% |
| |
Immunizations |
Covered in full |
Not Covered |
Not Covered |
Deductible, then 0% |
| |
Preventive Screenings
(includes Pap
Smear, PSA Testing, home colon cancer screening, cholesterol screening
and bone density test) |
Covered in full |
Covered in full |
Covered in full |
Deductible, then 0% |
| |
Office
Visits
(including Urgent Care &
Naturopathy) |
Deductible Waived;
$30
Copay |
Deductible waived
on first 6 visits then 25%; additional visits subject to
deductible then 25% |
Deductible waived
on first 3 visits at $25 copay; additional visits subject to deductible
then 25% |
Deductible, then 0% |
| |
Hospital
Inpatient/Outpatient |
Deductible, then 30% |
Deductible, then 25% |
Deductible, then 25% |
Deductible, then 0% |
| |
Outpatient Diagnostic Imaging & Lab Services |
Deductible, then 30% |
Deductible Waived, then 25%
for $1,850 plan only. Deductible, then 25% for all others |
Deductible, then 25% |
Deductible, then 0% |
| |
Mammography |
Deductible Waived, then 30% |
Deductible Waived, then 25% |
Deductible Waived, then 25% |
Deductible Waived, then 0% |
| |
Maternity Care (including prenatal care) |
Deductible, then 30% |
Not Covered |
Not Covered |
Not
Covered |
| |
Emergency Services (Worldwide coverage) |
$100 copay,
then subject
to deductible, then 30%.
(copay waived if
admitted.) |
$100 copay,
then subject
to deductible, then 25%.
(copay waived if
admitted.) |
$100 copay,
then subject
to deductible, then 25%.
(copay waived if
admitted.) |
$100
copay,
then subject to deductible, then 0%.
(copay waived if admitted.) |
| |
Rehabilitation (Physical,
Occupational, Speech & Massage Therapy; Cardiac & Pulmonary
Rehabilitation) |
Deductible, then 30%
Inpatient: 8 days PCY Outpatient: 20 visits PCY |
Deductible, then 25%
Inpatient: 8 days PCY Outpatient: 20 visits PCY |
Deductible, then 25%
Inpatient: 8 days PCY Outpatient: 20 visits PCY |
Deductible, then 0%
Inpatient: 8 days PCY
Outpatient: 20 visits PCY
|
| |
Durable
Medical Equipment & Prosthetics
($5,000 PCY) |
Deductible, then 30% |
Not Covered |
Not Covered |
Not
Covered |
| |
Skilled
Nursing Facility (45 days PCY) Includes
room & board, ancillaries & professional fees |
Deductible, then 30% |
Deductible, then 25% |
Deductible, then 25% |
Deductible, then 0% |
| |
Home
Health Care (130 visits PCY) |
Deductible, then 30% |
Deductible, then 25% |
Deductible, then 25% |
Deductible, then 0% |
| |
Hospice
Care (Inpatient: 10 days PCY; Respite:
240 hours PCY) |
Deductible, then 30% |
Deductible, then 25% |
Deductible, then 25% |
Deductible, then 0% |
| |
Acupuncture Services (12 visits PCY) |
Deductible Waived $25 Copay |
Deductible Waived $25 Copay |
Deductible Waived $25 Copay |
Deductible, then 0% |
| |
Spinal &
Other Manipulations (12 visits PCY) |
Deductible Waived $25 Copay |
Deductible Waived $25 Copay |
Deductible Waived $25 Copay |
Deductible, then 0% |
| |
Vision
Exam
(One routine exam per two
calendar years) |
Covered in Full |
Not Covered |
Not Covered |
Not
Covered |
| |
Vision
Hardware
(per two calendar years) |
$200 for frames, lenses &
contact lenses |
Not Covered |
Not Covered |
Not
Covered |
| |
Mental
Health - Outpatient Office Visit (6
visits PCY) |
Deductible Waived $30 Copay |
Deductible Waived, then 25% |
Deductible Waived $25 Copay |
Deductible, then 0% |
| |
Mental
Health - Inpatient Facility Care (6 days
PCY) |
Deductible, then 30% |
Deductible, then 25% |
Deductible, then 25% |
Deductible, then
0% |
| |
Pharmacy - Retail
(30-day supply)
Brand: $3,000 PCY limit;
Generic: Unlimited |
$10/30%/50%/30% |
Generics Only
Retail: $15 |
Not Covered
(Pharmacy discount program available) |
Not
Covered (Pharmacy discount program available) |
| |
Pharmacy - Mail Service
(90-day
supply)
Brand: $3,000 PCY limit; Generic: Unlimited |
$25/25%/45%/30% |
Generics Only
Mail Order: $40 |
Not Covered
(Pharmacy discount program available) |
Not
Covered (Pharmacy discount program available) |
| |
Transplants
(12-month waiting period;
$350,000 lifetime benefit) Organ & Bone Marrow |
Deductible, then 30% |
Deductible, then 25% |
Deductible, then 25% |
Deductible, then
0% |
| |
24 Hour
Coverage (when enrollee is not entitled
to receive Worker's Compensation) |
Yes |
Yes |
Yes |
Yes |
