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General Information: Index | Exclusions & Limitations | Locate Providers | Electronic Application
Benefit Schedules: Passport | Essentials 20 | HSA Plans
Arizona Health Insurance > LifeWise Health Plan of Arizona > Essentials 20 Benefits
Quote & Apply - Electronic Application
Deductible, coinsurance and copay represent what you pay. IN = In-network OUT = Out-of-network
| Lifewise Essentials 20 | Option 1 |
Option 2 |
||
| Select one of five Plan Deductible options: | In |
Out |
In |
Out |
| Annual Deductible (Individual) PCY (Family* is 3 times the individual deductible) | $2,500 |
$5,000 |
$5,000 |
$10,000 |
| Coinsurance† (What you pay) |
20% |
50% |
20% |
50% |
| Annual Coinsurance Maximum PCY | $3,000 |
$12,000 |
$3,000 |
$12,000 |
| Out-of-Pocket Maximum (Deductible + Coinsurance Max) |
$5,500 |
$17,000 |
$8,000 |
$22,000 |
| Office Visit Cost Share | 20% |
50% |
20% |
50% |
* Family = Individual plus one or more family members.
† All coinsurance amounts are the member’s percentage of allowable charges after deductible.
PCY = Per Calendar Year
| COVERED SERVICES | In-network provider |
Out-of-network provider* |
| Preventive Care | ||
| Preventive Exams (includes routine medical exam, sports physical, men’s and women’s health exam and well baby exam) | Covered in full† |
Deductible applies first, then you pay 50% |
| Preventive Screenings (includes Pap smear, PSA testing, home colon cancer screening, cholesterol screening and bone density test) | ||
| Immunizations | ||
| Health Education | ||
| Health Education & Wellness $200 PCY** | Covered in full†
|
|
| Nicotine Dependency Treatment $200 PCY** | ||
| Professional Care | ||
| Office Visit and Urgent Care | Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
| Inpatient and Outpatient Professional Services | ||
| Alternative Care | ||
| Spinal & Other Manipulations (includes chiropractic) | Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
| Acupuncture & Naturopathic Services 12 shared visits PCY | ||
| Diagnostic Services | ||
| Diagnostic X-ray & Imaging | Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
| Laboratory Services | No deductible; you pay 20% |
|
| Mammography | Covered in full† |
|
| Pharmacy | ||
| Prescription Drug Benefit (up to 30-day supply) | Deductible applies first, then you pay 20% |
|
| Emergency Care | ||
| Emergency Room Care (No copay if admitted) | $100 copay per visit, deductible applies and then you pay 20% |
|
| Ambulance Transportation (air and ground) | No deductible; you pay 20% |
|
| Facility Care | ||
| Outpatient Care | Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
| Inpatient Care (hospital room and board) | ||
| Skilled Nursing Facility 60 days PCY | ||
| Other Services | ||
| Rehabilitation (including Physical, Occupational, Speech, Massage Therapy; Chronic Pain; Cardiac & Pulmonary Rehabilitation) Outpatient: 20 visits PCY; Inpatient: 20 days PCY | Deductible applies first,
then you pay 20% |
Deductible applies first, then you pay 50% |
| Behavioral Health Care/Mental Health Outpatient: 10 visits PCY; Inpatient: 7 days PCY |
Deductible applies first, then you pay 50% |
|
| Home Health Care (covered only if prescribed in lieu of hospitalization) |
Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
| Hospice Care Inpatient: 10 days; Respite: 240 hours; home visits unlimited |
||
| Transplants $250,000 lifetime benefit | Deductible applies first, then you pay 20% |
Not covered |
| Lifetime Maximum | $3 Million |
|
* Balance billing may apply when an out-of-network provider is used.
** $200 PCY applies to both health education & wellness and nicotine dependency treatment.
† Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance.
NOTE: All coinsurance amounts are based on allowable charges. PCY = Per Calendar Year
This is only a summary of the major benefits provided by our Passport plans. It is not a contract.