Security Health Plan of Wisconsin, Inc.

SimplyOne Protection

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: No Charge after deductible CoInsurance: No Charge after deductible Covered: Covered
Specialist	CoPay: No Charge after deductible CoInsurance: No Charge after deductible Covered: Covered

Prescription Drug Information

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.
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: 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.
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 after deductible
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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