| |
HSA Plan |
Annual Deductible
Individual/Family |
$3,500/$7,000 |
Annual Out-of-Pocket Maximum
Individual/Family |
$5,250/$10,500 |
| Lifetime Maximum |
$2 million per person |
| Accidental Injury Benefit |
Does not apply |
After meeting your deductible, you pay the following
amounts for covered services:
(The deductible is waived for some covered services. These services are marked with †. |
| Preventive Care |
In-Plan |
Out-of-Plan |
|
Physician/Provider Services |
| Office visits to a personal physician/provider |
$20 per visit |
40% |
Periodic health exams, well-baby care
(from a Personal Physician/Provider only/limited to $250 per calendar year) |
$20 copay † |
40% |
| Office visits to all other physicians/providers |
20% |
40% |
| Routine immunizations/shots |
$20 per visit † |
40% |
| Alergy shots; serums; injectable medications |
20% |
40%
|
| Inpatient hospital visits |
20% |
40% |
| Surgery; anesthesia |
20% |
40% |
| Women's Health Services |
| Women's annual gynecological exam |
$20 per visit † |
40% |
| Follow-up visits after annual gynecological exam |
$20 per visit |
40% |
| Mammograms |
$20 † |
40% |
| Hospital Services |
| Inpatient care |
20% |
40% |
| Observation care |
20% |
40% |
Rehabilitative care
(30 days per calendar year) |
20% |
40% |
Skilled nursing facility
(60 days per calendar year) |
20% |
40% |
| Maternity Care |
| Prenatal and postnatal visits; delivery |
20% |
40% |
| Routine newborn nursery care |
20% |
40% |
| Hospital services |
20% |
40% |
| Emergency/Urgent care |
| Emergency services |
$250 |
| Urgent care services |
$20 per visit |
Emergency transportation services
($2,000 per calendar year) |
20% |
| Other Covered Services |
| Medical Supplies, including Diabetes Supplies |
20%
(deductible does not apply to purchase of diabetic supplies) |
40% |
Durable medical equipment, Appliances and Prosthetic Devices
(limited to $2,500 per calendar year, removable custom shoe orthotics limited to $200 per calendar year) |
20% |
40% |
| X-ray; Lab services |
20% |
40% |
| Imaging services (PET, CT, MRI) |
20% |
40% |
Outpatient rehabilitative services
(30 visits per calendar year) |
20% |
40% |
| Outpatient surgery, dialysis; infusion; chemotherapy; radiation therapy |
20% |
40% |
Home health care
(180 visits per calendar year) |
20% |
40% |
| Hospice care |
20% |
40% |
Self-administered chemotherapy
(up to a 30 day supply from a designated participating pharmacy)
- Generic drugs
- Formulary brand name drugs
- Non-formulary brand name drugs
|
$10
$50
$100 |
Not covered
Not covered
Not covered
|
Mental health
(limited to $2,000 per calendar year for all services, inpatient or outpatient)
Alcohol treatment
(limited to $4,500 every two years for all services)
Prior authorizations is required for all Mental Health and Alcohol Dependency treatment |
20% |
40% |
| Prescription Drugs |
| Covered at participating pharmacies
at the In-Plan benefit only |
Generic and brand-name drugs
(up to a 30-day supply) - 50% |
| A 90-day supply of certain maintenance
drugs may be purchased at a participating mail order pharmacy. |
LifeWise
HSA Plans
