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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 > Passport Benefits
Quote & Apply - Electronic Application
Deductible, coinsurance and copay represent what you pay. IN = In-network OUT = Out-of-network
| Lifewise Passport | Option 1 |
Option 2 |
Option 3 |
Option 4 |
Option 5 |
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| Select one of five Plan Deductible options: | In |
Out |
In |
Out |
In |
Out |
In |
Out |
In |
Out |
| Annual Deductible (Individual) PCY (Family* is 3 times the individual deductible) | $500 |
$1,000 |
$1,000 |
$2,000 |
$1,500 |
$3,000 |
$2,500 |
$5,000 |
$5,000 |
$10,000 |
| Coinsurance† (What you pay) |
20% |
50% |
20% |
50% |
20% |
50% |
20% |
50% |
20% |
50% |
| Annual Coinsurance Maximum PCY | $2,000 |
$8,000 |
$2,500 |
$10,000 |
$2,500 |
$10,000 |
$3,000 |
$12,000 |
$3,000 |
$12,000 |
| Out-of-Pocket Maximum (Deductible + Coinsurance Max) |
$2,500 |
$9,000 |
$3.500 |
$12,000 |
$4,000 |
$13,000 |
$5,500 |
$17,000 |
$8,000 |
$22,000 |
| Office Visit Cost Share | $20 copay |
50% |
$25 copay |
50% |
$30 copay |
50% |
$30 copay |
50% |
$30 copay |
50% |
Deductible, coinsurance and copay represent what you pa y. Benefits apply after calendar year deductible is met, unless otherwise noted as “no deductible,” “copay” or “covered in full.”
| 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) | Office visit copay |
Deductible applies first, then you pay 50% |
| Preventive Screenings (includes Pap smear, PSA testing, home colon cancer screening, cholesterol screening and bone density test) | Covered in full† |
|
| Immunizations | ||
| Health Education | ||
| Health Education & Wellness $200 PCY** | Covered in full†
|
|
| Nicotine Dependency Treatment $200 PCY** | ||
| Professional Care | ||
| Office Visit and Urgent Care | No deductible; office visit copay |
Deductible applies first, then you pay 50% |
| Inpatient and Outpatient Professional Services | Deductible applies first, then you pay 20% |
|
| Alternative Care | ||
| Spinal & Other Manipulations (includes chiropractic) | No deductible; office visit copay |
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) | $10 copay (generic drugs) $30 copay (preferred brand-name drugs) 50% (non-preferred brand-name drugs) |
|
| Mail Service (up to 90-day supply) | $25 copay (generic drugs) $75 copay (preferred brand-name drugs) 45% (non-preferred brand-name drugs) |
|
| 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 | Outpatient: No deductible; office visit copay
Inpatient: 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.
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