WorldIns - ExpressMed – ExpressMed Copay 80 PPO – Wisconsin

A comparison of the ExpressMed Copay 80 PPO offered by World is detailed out below for both Network and Non-Network coverage.

• Compare to other WorldIns - ExpressMed plans.

• Compare to all carriers in Wisconsin.

	Network	Non-Network
Network	See Provider	See Provider
Application	ExpressMed Copay 80 PPO Application	ExpressMed Copay 80 PPO Application
Brochure	ExpressMed Copay 80 PPO Brochure	ExpressMed Copay 80 PPO Brochure
Copay	$40	Subject to deductible and coinsurance
Office Visit	$40 (related expenses, such as x-rays and lab tests, are subject to deductible and coinsurance)	Subject to deductible and coinsurance
Deductible	$5,000 Maximum of 3 per family, per calendar year	$1,000 more than the In-Network deductible Maximum of 3 per family, per calendar year
Coinsurance	80%	60%
Coinsurance Limit	You pay 20% of next $10,000 after deductible	You pay 40% of next $10,000 after deductible
Out-of-Pocket Maximum	$7,000 (includes deductible)	$10,000 (includes deductible)
Lifetime Maximum	$3 million	$3 million
Prescription Drugs	Generic- $10 or 20% (of the drugs cost, whichever is greater) Brand-name: Subject to deductible and coinsurance; discount drug card provides first-dollar discounts	Generic- $10 or 20% (of the drugs cost, whichever is greater) Brand-name: Subject to deductible and coinsurance; discount drug card provides first-dollar discounts
Emergency Room	Provides 100% coverage up to $1,000 (coverage for sickness or injury) after a $150 copayment, then subject to deductible and coinsurance	Provides 100% coverage up to $1,000 (coverage for sickness or injury) after a $150 copayment, then subject to deductible and coinsurance
Adult Preventative Care	Wellness Benefit- covers up to $250 in wellness benefits per calendar year, after a $40 copayment. Wellness benefits include routine physicals, screenings and immunizations not specifically covered under the policy/certificate.	see brochure
Child Preventative Care	see brochure	see brochure
Lab / X-Ray	Subject to deductible and coinsurance	Subject to deductible and coinsurance
Maternity	Pregnancy or childbirth is not covered, except for complications of pregnancy	Pregnancy or childbirth is not covered, except for complications of pregnancy
Physical Therapy	Covered as any other illness or injury (LA- $150 per visit and $100,000 lifetime maximum)	Covered as any other illness or injury (LA- $150 per visit and $100,000 lifetime maximum)
Skilled Nursing	Covered up to 60 days in a calendar year	Covered up to 60 days in a calendar year
Home Health Care	Covered 40 visits per calendar year	Covered 40 visits per calendar year
Mental Health	see brochure	see brochure
Hospital Care	Subject to deductible and coinsurance	Subject to deductible and coinsurance
Optional Benefits	Prescription Drug Copay Benefit: $250 calendar year prescription drug deductible, then Generic- $10 or 20%; Brand-name (formulary)- $30 or 50% (40% in GA); Brand-name (non-formulary)- $40	Prescription Drug Copay Benefit: $250 calendar year prescription drug deductible, then Generic- $10 or 20%; Brand-name (formulary)- $30 or 50% (40% in GA); Brand-name (non-formulary)- $40