Plan Name |
WiseAdvantage |
WiseEssentials Rx |
WiseEssentials Rx |
WiseEssentials Copay |
WiseSimplicity |
WiseSavings HSA qualified (individual) |
WiseSavings HSA qualified (family) |
Comprehensive
OR
Catastrophic |
Comprehensive |
Catastrophic |
Catastrophic | Catastrophic | Catastrophic |
Catastrophic |
Catastrophic |
Annual Deductible |
Option A:
$1,800 individual/ $5,400 family |
$1,880 per person |
Option A: $2,500 per person
Option B: $3,500 per family |
Option A: $5,000 per person
Option B: $7,500 per family |
$10,000 per person |
$1,880 |
$3,760 |
Individual Out-of-Pocket Maximum |
$6,500 |
$5,000 per person |
$5,000 per person |
$5,000 per person |
$0 |
$2,500 |
N/A |
Family Out-of-Pocket Maximum |
$19,500 |
Based on Covered Individuals |
Based on Covered Individuals |
Based on Covered Individuals |
No Maximum |
N/A |
$5,000 |
| Out-of-Network Co-Insurance |
50% |
50% |
50% |
50% |
50% |
50% |
50% |
Lifetime Maximum |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
$2 Million |
$2 Million |
$2 Million |
After deductible (or applicable co-pay) is met; in-network 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 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 |
$25 co-pay NO deductible |
0% after deductible |
20% after deductible |
20% after deductible |
Preventive Care |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
100% NO deductible |
Outpatient Lab & X-ray |
35% after deductible |
25% NO deductible |
25% NO deductible |
25% after deductible |
0% after deductible |
20% after deductible |
20% after deductible |
| ER Services (co-pay waived if admitted) |
$100 co-pay; then 35% after deductible |
$100 co-pay; then 25% after deductible |
$100 co-pay; then 25% after deductible |
$100 co-pay; then 25% after deductible |
$100 co-pay; then 100% after deductible |
20% after deductible |
20% after deductible |
Hospital Services - Inpatient |
35% after deductible |
25% 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 |
Not Covered |
Prescription Drugs |
$10 co-pay preferred generic / 50% non-preferred generic |
$15 co-pay (Generics Only) |
$15 co-pay (Generics Only) |
Rx Discount Program Included |
Rx Discount Program Included |
Rx Discount Program Included |
Rx Discount Program Included |
Mental Health Services
(outpatient services billed like any other office visit) |
$30 co-pay NO deductible (outpatient) / 35% after deductible (inpatient) |
First 6 visits you pay 25% NO deductible; All others 25% after 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 |
100% after deductible |
20% after deductible |
20% after deductible |
Vision Exam |
1 exam covered in full |
Not Covered |
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 |
Not Covered |
| |
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