|
|
HSA Qualified Plan
|
| Find a doctor in this directory |
|
| Lifetime benefit maximum |
$2 million per individual
|
| Benefit Features |
In-Network Benefit
|
Out-Of-Network Benefit
|
| Deductibles |
Single - $1,500, $2,500, $3,500
Family - $3,000, $5,000, $7,000
|
| Out-of-pocket maximum amount
per calendar year including deductible |
Single - $5,000
Family - $10,000
|
None
|
| After your maximum coinsurance
is met each calendar year, we pay |
100%
|
N/A
|
Preventative Care Services
(Click
to see preventive care schedule) |
After Deductible We Pay
|
| Immunizations for adults and children |
80%
|
60%
|
| Well-baby exam to age 2 |
80%
|
60%
|
| Annual women's exams including
Pap and mammogram |
80%
|
60%
|
| Professional Services |
After Deductible We Pay
|
| Office visits and other office
procedures |
80%
|
60%
|
| Diagnostic radiology and lab |
80%
|
60%
|
| Therapeutic injections and allergy
shots |
80%
|
60%
|
| Surgery |
80%
|
60%
|
| Maternity care |
80%
|
60%
|
Hospital Services
(Click
for Emergency care guidelines) |
After Deductible We Pay
|
Emergency room for medical emergency
|
80%
|
| Emergency room for non-emergency |
80%
|
60%
|
Inpatient stay
(including
maternity, surgery, and rehabilitation) |
80%
|
60%
|
| Outpatient services including surgery,
diagnostic radiology, and lab |
80%
|
60%
|
| Other Services |
After Deductible We Pay
|
| Ambulance |
80%
|
| Prescription medication |
50%
|
| Alcoholism treatment |
80%
|
60%
|
Rehabilitation
(physical,
speech, and occupational therapy) |
80%
|
60%
|
| Skilled nursing facility, home health,
and hospice care |
80%
|
60%
|
| Durable medical equipment and supplies |
80%
|
60%
|
|
Additional Benefits
|
| Accidental death |
Provide $25,000 for
you and your enrolled adult spouse, $5,000 for each enrolled
dependent or a subscriber under the age of 18. |
| Special Beginnings ® |
Provides a maternity
program designed to promote healthy prenatal care through
education and support |
| BlueCard ® program |
Provides savings
nationwide. To receive the best benefit, please
use BlueCard PPO providers of the Blue Cross and/or Blue
Shield Plan in the area where you receive the service. |
| |
LifeWise
HSA Plans
