Arise Health Plan

WPS HMO Bronze $8,700 | Select Network

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

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: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
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/2022/84670WI1250149-01.pdf Limit Unit : https://www.wpshealth.com/resources/sbc/files/2022/84670WI1250149-01.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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