LifeWise Essential Gold – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $65 copay
Urgent care visit: $55 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $7,300 per person $14,600 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $55 copay |
| Emergency room | 30% after deductible |
| Ambulance | 30% after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | 30% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | 30% after deductible |
| Non-preferred Brand | 40% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | 30% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/jnRMA2CyQGjposN361YfDGcW.pdf |
| Drug and medication plan formulary | https://www.lifewisewa.com/documents/052167_2024.pdf |
