(844) 967-1917
Arise Health Plan

WPS HMO HDHP Bronze $6,830 | Select Network

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $6,830.00
  • Family: $13,660
  • Per Person: $6,830
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $6,830.00
  • Family: $13,660
  • Per Person: $6,830

Office Visit

Primary Doctor
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: 3 Free Office Visits Per Year Per Family Member
Specialist
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Item(s) per Month
  • Benefit Explanation: Coverage limited to 90-day supply retail and mail order.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Item(s) per Month
  • Benefit Explanation: Coverage limited to 90-day supply retail and mail order.
Generic Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Item(s) per Month
  • Benefit Explanation: See formulary for a listing of free preventive drugs. Coverage limited to 90-day supply for retail and mail order.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Item(s) per Month
  • Benefit Explanation: Coverage limited to 30-day supply.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Services provided by a non-participating provider will be paid at the participating provider level.
Urgent Care Facility
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Services provided by a non-participating provider will be paid at the participating provider level if for emergency medical care.

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Exclusions: No coverage for home births.
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Exclusions: No coverage for birthing classes.

Vision

Routine Eye Exams For Children
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
  • Exclusions: Coverage is limited to children through the last day of the calendar month of their 19th birthday; no coverage for services by a non-participating provider.",",",",Not Covered"

Major Dental Care

Routine Dental Checkups for Children
  • Exclusions: Not Covered
Major Dental Care - Child
  • Limit Quantity: https://www.wpshealth.com/documents/Brochure/2022/84670WI1250158-01.pdf
  • Limit Unit : https://www.wpshealth.com/resources/sbc/files/2022/84670WI1250158-01.pdf
  • Exclusions: https://secure.wecareforwisconsin.com/visitors/find_a_doctor/
  • Benefit Explanation: https://wpshealth.com/resources/customer-resources/pharmacy-info.shtml
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