| |
Elect FlexPerks (HSA-Qualified) |
| Maximum Lifetime Benefit
|
$2,000,000 |
| |
Annual Deductible |
Out-of-Pocket Limit(individual / family) |
Participating Provider Annual Deductible &
Out-of-Pocket (OOP) Limit
(Copayments and deductible apply to out-of-pocket
limit)
|
$1,500 per person / $3,000 per family |
$5,000/$10,000 |
|
$2,000 per person / $4,000 per family |
$5,000/$10,000 |
|
$2,900 per person / $5,800 per family |
$5,600/$11,200 |
|
$5,000 per person / $10,000 per family |
$5,000/$10,000 |
|
Out-of-Pocket Limit, Nonparticipating Provider
(Minus the amount of the plan’s deductible) |
$10,000 per person |
Accident Benefit
(accident-related covered expenses) |
The first $1,000 within 90 days is covered at 100%, deductible waived. |
| Preventive Care |
Participating Providers |
Non-Participating Providers
3 |
| Well Baby Care |
70% 5 |
50% 4 |
| Routine Physicals and Preventive Care Exams |
70% 2, 5 |
50% 2, 4 |
| Routine Gynecological Exams |
70% 5 |
50% 4 |
| Immunizations |
70% 5 |
50% 4 |
| Professional Services |
| Office and Home Visits |
70% 1 |
50% |
| Surgery |
70% 1 |
50% |
| Chiropractic Manipulation |
Not covered |
Not covered |
| Acupuncture |
Not covered |
Not covered |
| Naturopathic
Care |
Not covered |
Not covered |
| Maternity Care |
| Practitioner Services |
70% 1 |
50% |
| Hospital Stay |
70% 1 |
50% |
| Hospital Services |
| Inpatient Room and Board |
70% 1 |
50% |
| Inpatient Rehabilitative Care |
70% 1 |
50% |
| Skilled Nursing Facility Care |
70% 1 |
50% |
| Outpatient Services |
| Outpatient Hospital/Facility |
70% 1 |
50% |
| Diagnostic & Therapeutic
Radiology and Lab |
70% 1 |
50% |
| CT/PET Scans, Cath Labs, and MRIs |
70% 1 |
50% |
| Emergency Room Visits |
70% 1 |
50% |
| Urgent Care Center Visits |
70% 1 |
50% |
| Other Covered Services |
| Prescription Drugs |
50% 1 |
Not Covered |
| Physical Therapy |
70% 1 |
50% |
| Allergy Injections |
70% 1 |
50% |
| Ambulance Service |
70% 1 |
50% |
| Durable Medical Equipment/Prosthesis |
70% 1 |
50% |
| Home Health, Hospice, and
Respite Care |
70% 1 |
50% |
| Inpatient Mental Health Services |
70% 1 |
50% |
| Transplant Services |
70% 1 |
Lesser of 50% of billed amount or $100,000 |
Note:
1 = Covered at 100% under the Elect FP 5000 plan (after deductible)
2 = Scheduled benefit
3 = Payment to providers is based on the PacificSource fee allowance.
While participating providers accept the fee allowance as payment in full,
nonparticipating providers may not. Services of nonparticipating providers
could result in out-of-pocket expense in addition to the percentage indicated.
4 = Not subject to the annual deductible , except on the Elect FP 5000 plan.
5 = Not subject to annual deductible, except on the Elect FP
5000 plan. Preventive Care Services on the Elect FP 5000 plan are paid at 100% after deductible for participating providers |
LifeWise
HSA Plans
