Plan Name |
WiseChoices Prime |
WiseEssentials Rx |
WiseEssentials Copay |
WiseSimplicity |
WiseSavings HSA qualified (individual) |
WiseSavings HSA qualified (family) |
Comprehensive
OR
Catastrophic |
Comprehensive | Catastrophic | Catastrophic | Catastrophic |
Catastrophic |
Catastrophic |
Annual Deductible |
Option A:
$1,500 individual/ $4,500 family
Option B:
$3,000 individual/ $9,000 family |
Option A:
$1,850 per person
Option B:
$2,500 per person |
Option A:
$5,000 per person
Option B:
$7,500 per person |
$10,000 per person |
$1,850 |
$3,700 |
Individual Out-of-Pocket Maximum |
$6,500 |
$5,000 |
$5,000 |
$0 |
$2,500 |
N/A |
Family Out-of-Pocket Maximum |
$19,500 |
No Maximum |
No Maximum |
No Maximum |
N/A |
$5,000 |
Lifetime Maximum |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
After deductible (or applicable co-pay) is met; benefits will be paid as follows by covered member: |
Office Visits |
$30 co-pay NO deductible |
First 6 visits you pay 25% NO deductible; All others 25% after deductible |
First 3 visits you pay $25 NO deductible; All others 25% after deductible |
0% after deductible |
20% after deductible |
20% after deductible |
Alternative Care (i.e. Acupuncture 12 or Chiropractic 12) |
$25 co-pay NO deductible |
$25 co-pay NO deductible |
$25 co-pay NO deductible |
0% after deductible |
20% after deductible |
20% after deductible |
Preventive Care |
$30 co-pay NO deductible |
Shared with 6 office visits |
Shared with 3 office visits |
1 exam PCY 0% NO deductible |
Covered in full up to $300 |
Covered in full up to $300 |
Outpatient Lab & X-ray |
30% after deductible |
25% NO deductible |
25% after deductible |
0% after deductible |
20% after deductible |
20% after deductible |
Hospital Services - Inpatient |
30% after deductible |
25% after deductible |
25% after deductible |
0% after deductible |
20% after deductible |
20% after deductible |
Maternity Services |
30% after deductible |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Prescription Drugs |
$10 co-pay generic/ 30% tier 1/ 50% tier 2/ 30% tier 3, Rx max of $3,000 brand ONLY |
$15 co-pay (Generics Only) |
Rx Discount Program Included |
Rx Discount Program Included |
Rx Discount Program Included |
Rx Discount Program Included |
Vision Exam |
1 exam covered in full |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Vision Hardware |
Up to $200 |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
| |
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