Presents
For employer groups
This plan is available as a full benefit plan
Presents
Single/$6,000 Family
Single/$1,000 Family
(Reduced Deductible based on wellness points earned)
Single/$10,000 Family
$16,000 Single/$24,000 Family
(OOP Limit does not include copays and Rx copays)
Unlimited
-Primary Care Office Visit
Deductible/Co-insurance
-Specialist Office Visit
Deductible/Co-insurance
-Physician & Surgeon Professional Services
Deductible/Co-insurance
-Anesthesia Services (Physician/CRNA)
Deductible/Co-insurance
Copay
Deductible/Co-insurance
Deductible/Co-insurance
certification required to
scheduling for MRI, CT, PET
Nuclear Imagin
-Physician Office/Freestanding Imaging Ctr
Deductible/Co-insurance
-Hospital Outpatient
Copay, then Deductible/
insurance
Deductible/Co-insurance
Deductible/Co-insurance
Deductible/Co-insurance
Deductible/Co-insurance
Copay waived if admitted
-Hospital ER (Facility Charge Only)
copay then deductible
insurance
-Urgent Care/ER Professional Services
Deductible/Co-insurance
-Ambulance
Deductible/Co-insurance
-Air Ambulance
$2,500 Copay then
Deductible/Co-insurance
certification required prior to
scheduling
-Physician Office/Freestanding Surgery Ctr.
Deductible/Co-insurance
-Hospital Outpatient
$1,000 Copay per visit then
Deductible/Co-insurance
-Implant Device
Deductible/Co-insurance***
-Medical Facility Services
Copay then Deductible/
insurance
-Anesthesiologist & Surgeon Fees
Deductible/Co-insurance
Deductible/Co-insurance
-Implant Device
Deductible/Co-insurance***
Deductible/Co-insurance
Deductible/Co-insurance
Deductible/Co-insurance
-Generic
covered
-Brand/Non-Preferred Brand/Specialty
covered
-International Mail Order-Brand
covered
$1,500 Single/$2,000 Family
$500 Single/$1,000 Family
20%
$2,500 Single/$5,000 Family
$4,000 Single/$8,000 Family
$7,350 Single/$14,700 Family
100%
$30 Copay then 100% to $250 per visit*
$50 Copay then 100% to $250 per visit**
Deductible/Co-insurance
Deductible/Co-insurance
$0 Copay
100% if prefered vendor, otherwise
Deductible/Co-insurance
Pre-certification required prior to scheduling
for MRI, CT, PET and Nuclear imaging
Deductible/Co-Insurance
$500 copay, then Deductible/Co-insurance
100% if preferred vendor, otherwise
50% cost through Rx Benefit
$25 Copay, then 100% to $100 per visit
Deductible/Co-insurance
Deductible/Co-insurance
Copay waived if admitted
$250 Copay then Deductible/Co-insurance
$50 Copay, then 100% to $500 per visit
then Deductible/Co-insurance
Deductible/Co-insurance
$2,500 Copay then Deductible/Co-insurance
Pre-certification requiered prior to scheduling
Deductible/Co-insurance
$1,000 copay per visit then Deductible/
Co-insurance
Deductible/Co-insurance***
$500 Copay then Deductible/Co-insurance****
Deductible/Co-insurance
Deductible/Co-insurance
Deductible/Co-insurance***
Deductible/Co-insurance
Deductible/Co-insurance
Deductible/Co-insurance
Refer to Preferred Formulary & SPD for details
$1 Copay/$15 copay
$50 Copay/$80 Copay/50%
$0 Copay if preferred vendor*****
$3,000
$500
50%
$5,000
$8,000
100%
$0
Pre-
and
$500
Co-
$250
Co-
Pre-
$500
Co-
Not
Not
Not
IMPORTANT NOTES:
*$30 Copay then 100% TO $250 per visit for all services provided during visit except Lab services, then Deductible/Co-insurance **$50 Copay then 100% to $250 per visit for all services provided during visit except Lab services, then Deductible/Co-insurance ***Deductible/Co-insurance (benefit Max of 200% of manufactures invoice or scheduled benefit pricing, whichever is greater) ****$500 Copay per confinement. All non-emergency confinements must be pre-certified and emergency confinements must be reported with 48 hours of when
confinement begings.
*****Participation in Mall Order Program is voluntary
This outline is intended as a brief of the actual plan and representative benefit levels. Certain procedures requiere pre-certification prior to scheduling in order to qualify for benefits. Failure to do so will result in penalties and/or non coverage of servies. Please refer to your Summary Plan Dcomuent (SPD) for the actual benefits. Limitations and exclutions if there is any inconsistency between this outline and the SPD, the SPD shall govern. You may request a SPD from Lifestyle Health Plans or your sales representative. Certain procedures requiere pre-certification prior to scheduling in order to quality for benefits. Failure to do so will result in penalties and/or non coverage of services.