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                LifeWise Individual Health Plans - 2012 Benefit Summary*       

  Benefits               WiseAdvantage WiseEssentials Rx WiseEssentials Copay WiseSimplicity
  Annual Deductible PCY (choose one) Individual:  $1,800
Family:  $5,400		 $1,880, $2,500 or $3,500 $5,000 or $7,500 $10,000
  Coinsurance
(what you pay)		 35% 25% 25% 0%
Annual Coinsurance Maximum
(once met, preferred providers covered in full)		 $6,500 Indiv. or
Family = 3x Indiv.		 $5,000 per Individual $5,000 per Individual $0
  Calendar Year Maximum
(per individual)		 $2 Million $2 Million $2 Million $2 Million
  Preventive Care Exams
(routine medical exam, sports physical, and well baby exam)		 Covered in full Covered in full Covered in full Covered in full
(1 exam PCY, well-baby exams are unlimited)
  Immunizations Covered in full Covered in full Covered in full Covered in full
  Preventive Screenings
(includes mammograms & colonoscopies)		 Covered in full Covered in full Covered in full Covered in full
  Office Visits
(including Urgent Care & Naturopathy)		 Deductible Waived;
$30 Copay		 Deductible waived on first 6 visits then 25%; additional visits subject to deductible then 25% Deductible waived on first 3 visits at $25 copay; additional visits subject to deductible then 25% Deductible, then 0%
  Hospital Inpatient/Outpatient Deductible, then 35% Deductible, then 25% Deductible, then 25% Deductible, then 0%
  Outpatient Diagnostic Imaging & Lab Services Deductible, then 35% Deductible Waived, then 25% for $1,880 plan only.  Deductible, then 25% for all others Deductible, then 25% Deductible, then 0%
  Maternity Care (including prenatal care) Deductible, then 35% Not Covered Not Covered Not Covered
  Emergency Room Care (Worldwide coverage) $100 copay,
then subject to deductible, then 35%. 

(copay waived if admitted)		 $100 copay,
then subject to deductible, then 25%. 

(copay waived if admitted)		 $100 copay,
then subject to deductible, then 25%. 

(copay waived if admitted)		 $100 copay,
then subject to deductible, then 0%. 

(copay waived if admitted)
  Rehabilitation  (Physical, Occupational, Speech & Massage Therapy; Cardiac & Pulmonary Rehabilitation) Deductible, then 35%

 Inpatient:  8 days PCY Outpatient:  20 visits PCY		 Deductible, then 25%

 Inpatient:  8 days PCY Outpatient:  20 visits PCY		 Deductible, then 25%

 Inpatient:  8 days PCY Outpatient:  20 visits PCY
Deductible, then 0%

Inpatient:  8 days PCY Outpatient:  20 visits PCY
  Durable Medical Equipment & Prosthetics Deductible, then 35% Not Covered Not Covered Not Covered
  Skilled Nursing Facility (45 days PCY) Includes room & board, ancillaries & professional fees Deductible, then 35% Deductible, then 25% Deductible, then 25% Deductible, then 0%
  Home Health Care (130 visits PCY) Deductible, then 35% Deductible, then 25% Deductible, then 25% Deductible, then 0%
  Hospice Care (Inpatient: 10 days PCY; Respite: 240 hours PCY) Deductible, then 35% Deductible, then 25% Deductible, then 25% Deductible, then 0%
  Acupuncture Services
(12 visits PCY)		 Deductible Waived
$25 Copay		 Deductible Waived
$25 Copay		 Deductible Waived
$25 Copay		 Deductible, then 0%
  Spinal & Other Manipulations (12 visits PCY) Deductible Waived
$25 Copay		 Deductible Waived
$25 Copay		 Deductible Waived
$25 Copay		 Deductible, then 0%
  Vision Exam
(One routine exam per two calendar years)		 Covered in Full Not Covered Not Covered Not Covered
  Vision Hardware
(per two calendar years)		 $200 for frames, lenses & contact lenses Not Covered Not Covered Not Covered
  Mental Health - Outpatient Office Visit Deductible Waived
$30 Copay		 Deductible waived on first 6 visits then 25%; additional visits subject to deductible then 25% Deductible waived on first 3 visits at $25 copay; additional visits subject to deductible then 25% Deductible, then 0%
  Mental Health - Inpatient Facility Care Deductible, then 35% Deductible, then 25% Deductible, then 25% Deductible, then 0%
  Pharmacy - Retail
(30-day supply)		 $15/50% Generics Only
Retail: $15		 Not Covered (Pharmacy discount program available) Not Covered (Pharmacy discount program available)
  Pharmacy - Mail Service
(90-day supply)		 $45/50% Generics Only
Mail Order: $40		 Not Covered (Pharmacy discount program available) Not Covered (Pharmacy discount program available)
  Transplants
(12-month waiting period) Organ & Bone Marrow		 Deductible, then 35% Deductible, then 25% Deductible, then 25% Deductible, then 0%
  24 Hour Coverage (when enrollee is not entitled to receive Worker's Compensation) Yes Yes Yes Yes

*This is an overview of Preferred Provider Network deductible, coinsurance and copay levels only.  Non-Preferred Provider deductible, coinsurance and copay levels are not shown and are higher in most instances.  Preferred Provider Directory.

**Pharmacy discount program.  Instantly save on qualifying drugs at select retail pharmacies.  Simply show your LifeWise ID card at any participating network pharmacy.  Compare prescription medication costs.

This is only a summary of the major benefits provided by LifeWise.  This is not a contract.  See Benefit Booklet/Contract for specific coverage information.

Questions?  800-877-8019                                                                                             Copyright 2012, Green Financial, All Rights Reserved

 




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