MDwise Healthy Indiana Plan Buy-In Benefit Summary
Plan Overview | Application Instructions | Rate Sheet 
| Preferred Drug List
| Annual Maximum | $300,000 |
| Lifetime Maximum | $1,000,000 |
| Deductible
(member out of pocket expense) |
$1,100 |
| Emergency Care | $25.00 member copayment If true emergency or admitted to the hospital, no copay is required |
| Preventive Care Services This includes annual check-ups; annual screenings recommended by your doctor and according to preventive care guidelines for your age and gender |
100% coverage by MDwise |
| Family Planning Services | Member pays until yearly deductible is satisfied then MDwise pays 100% |
| Prescription Drugs Use of the Indiana drug formulary is required and Generic drugs are required, if available |
Member pays until yearly deductible is satisfied then MDwise pays 100% |
| Organ and Tissue Transplant Services | Member pays until yearly deductible is satisfied then MDwise pays 100% |
| Inpatient Hospital Care Outpatient Hospital Care Physician Office Visits Outpatient Diagnostic X-rays and Lab Tests Inpatient and Outpatient Mental/Behavioral Health Medical Supplies, DME and Prosthetics Outpatient Therapy Services Ambulance (Emergency Transportation Only) |
Member pays until yearly deductible is satisfied then MDwise pays 100% Maximums per benefit period: Physical Therapy - 25 visits Occupational Therapy - 25 visits Speech Therapy - 25 visits |
| Pregnancy Care Dental Vision |
Not Covered |
| Out of Network Services (except emergency care and family planning) |
Not Covered |
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