(844) 967-1917
Security Health Plan of Wisconsin, Inc.

Enrich $8,700 Copay

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $8,700.00
  • Family: $17,400
  • Per Person: $8,700
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700.00
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: $35.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $115.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Non Preferred Brand Drugs
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Generic Drugs
  • CoPay: $25.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Specialty Drugs
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

Inpatient Coverage

Hospital Services
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.
Urgent Care Facility
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.

Maternity

Labor and Delivery Hospital Stay
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: prenatal cradle (maternity belt), home delivery and home visits, services performed by a licensed midwife or certified professional midwife, services to determine gender, abortion procedures to end a pregnancy except as specifically stated above.
Pre and Postnatal Office Visit
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Routine Dental Checkups for Adults
  • Covered: Not Covered
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