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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 > HSA Plan Benefits
Quote & Apply - Electronic Application
Deductible, coinsurance and copay represent what you pay. IN = In-network OUT = Out-of-network
| Individual Plan (subscriber only) |
Lifewise HSA 20 |
Lifewise
HSA |
||
| Select LifeWise HSA 20 or LifeWise HSA plan | In |
Out |
In |
Out |
| Annual Deductible PCY | $3,000 |
$6,000 |
$5,000 |
$10,000 |
| Coinsurance† (What you pay) |
20% |
50% |
0% |
50% |
| Annual Coinsurance Maximum PCY | $2,000 |
Unlimited |
$0 |
Unlimited |
| Out-of-Pocket Maximum (Deductible + Coinsurance Max) |
$5,000 |
Unlimited |
$5,000 |
Unlimited |
| Office Visit Cost Share | 20% |
50% |
0% |
50% |
| Family Plan* (subscriber plus one or more) |
Lifewise HSA 20 |
Lifewise
HSA |
||
| Select LifeWise HSA 20 or LifeWise HSA plan | In |
Out |
In |
Out |
| Annual Deductible PCY | $6,000* |
$12,000* |
$10,000* |
$20,000* |
| Coinsurance† (What you pay) |
20% |
50% |
0% |
50% |
| Annual Coinsurance Maximum PCY | $4,000 |
Unlimited |
$0 |
Unlimited |
| Out-of-Pocket Maximum (Deductible + Coinsurance Max) |
$10,000 |
Unlimited |
$10,000 |
Unlimited |
| Office Visit Cost Share | 20% |
50% |
0% |
50% |
† All coinsurance amounts are the member’s percentage of allowable charges after deductible.
* Services for all family members covered under the same HSA-qualified plan get applied to the same deductible.
The family deductible must be met before services are covered for any enrolled family members.
PCY = Per Calendar Year
Lifewise HSA 20 |
Lifewise HSA |
|||
| COVERED SERVICES | In-network |
Out-of-network* |
In-network |
Out-of-network* |
| Preventive Care | ||||
| Preventive Exams (includes routine medical exam, sports physical, men’s and women’s health exam and well baby exam) $300 PCY | Covered in full† |
Deductible applies first, then you pay 50% |
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 (unlimited) | ||||
| Health Education | ||||
| Diabetes Health Education & Wellness (unlimited) | Deductible applies first,
then you pay 20% |
Deductible applies first, then you pay 50% | Deductible applies first, then covered in full | Deductible applies first, then you pay 50% |
| Nicotine Dependency Treatment | Not covered |
Not covered |
||
| Professional Care | ||||
| Office Visit and Urgent Care | Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
Deductible applies first,
then covered in full |
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% |
Deductible applies first,
then covered in full |
Deductible applies first,
then you pay 50% |
| Acupuncture & Naturopathic Services | Not covered |
Not covered |
||
| Diagnostic Services | ||||
| Diagnostic X-ray & Imaging | Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
Deductible applies first,
then covered in full |
Deductible applies first, then you pay 50% |
| Laboratory Services | ||||
| Mammography | Covered in full† |
Covered in full† |
||
| Pharmacy | ||||
| Prescription Drug Benefit (up to 30-day supply) | Deductible applies first, then you pay 20%
(Preventive generic cardiac drugs are
reimbursed at 100%†) |
Deductible applies first, then covered in full
(Preventive generic cardiac drugs are
reimbursed at 100%†) |
||
| Emergency Care | ||||
| Emergency Room Care (No copay if admitted) | Deductible applies first,
then you pay 20% |
Deductible applies first, then covered in full |
||
| Ambulance Transportation (air and ground) | ||||
| Facility Care | ||||
| Outpatient Care | Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
Deductible applies first, then covered in full |
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% |
Deductible applies first, then covered in full |
Deductible applies first, then you pay 50% |
| Behavioral Health Care/Mental Health Outpatient: 10 visits PCY; Inpatient: 7 days PCY |
||||
| Home Health Care (covered only if prescribed in lieu of hospitalization) |
||||
| 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 |
Deductible applies first, then covered in full |
Not covered |
| Lifetime Maximum | $3 Million |
|||
* Balance billing may apply when an out-of-network provider is used.
† 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.
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