LifeWise Cascade Select Gold – EPO

Network type: EPO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $40 copay
Urgent care visit: $35 copay

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Description

Health Care Plan Details

Network type EPO
Deductible $600 per person $600 per person
Out-of-pocket max $6,100 per person $12,200 per family
Metal tier Gold

Visit Copay

Primary care visit $15 copay
Specialist visit $40 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $35 copay
Emergency room $450 copay after deductible
Ambulance $375 copay
Hospital stay (facility) first 5 day(s) $525 per day then $0 copay
Hospital stay (physician) No charge
Outpatient procedure (facility) $350 copay after deductible
Outpatient procedure (physician) $75 copay after deductible
Physical rehabilitation $25 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay first 5 day(s) $525 per day then $0 copay

Pharmacy, Drugs, and Medication

Generic $10 copay
Brand $60 copay
Non-preferred Brand $100 copay
Specialty $100 copay

Lab Tests and Diagnostic Procedures

X-rays $30 copay
Imaging (CT/PET/MRI) $300 copay after deductible
Blood work $20 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $15 copay
Psychiatric hospital stay first 5 day(s) $525 per day then $0 copay

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/cijkLZvmiRio8F2BwyTDMXWN.pdf
Drug and medication plan formulary https://www.lifewisewa.com/documents/052167_2024.pdf