The Pre-existing Condition Insurance Plan–Washington State offers two PPO benefit plan options: a $2,500 deductible plan and $500 deductible plan. Both plans include:

Comprehensive coverage for preventive care, primary and specialty care, hospital care, and prescription drugs
Disease management programs, and
Case management services.

There is no deductible for pharmacy benefits, no lifetime maximum, and no pre-existing condition waiting periods.

$2,500 Deductible	$500 Deductible
An annual deductible of $2,500 for medical benefits. No deductible for pharmacy benefits.	An annual deductible of $500 for medical benefits. No deductible for pharmacy benefits
Coinsurance of 20% in network and 40% out of network for medically necessary medical services.	Coinsurance of 20% in network and 40% out of network for medically necessary medical services.
$10 copay for generic drugs, 30% coinsurance for preferred brand drugs, and 50% coinsurance for non-preferred brand drugs. A 90-day supply by mail order for two times the 30-day copay.	$2 copay for generic drugs, 10% coinsurance up to $50 maximum for preferred brand drugs, and 15 % coinsurance up to $100 maximum for non-preferred brand drugs. A 90-day supply by mail order for two times the 30-day copay.
A maximum out-of-pocket of $4,950 for medical benefits and $1,000 for pharmacy benefits.	A maximum out-of-pocket of $1,000 for medical benefits and $500 for pharmacy benefits.
Preventive care covered with no cost sharing.	Preventive care covered with no cost sharing.
Certified diabetes education with no cost sharing.	Certified diabetes education with no cost sharing (certified only).
A 12-visit annual limit for acupuncture and massage therapy (when prescribed by a physician).	A 12-visit annual limit for acupuncture and massage therapy (when prescribed by a physician).
A 100-day annual limit for skilled nursing facility care.	A 100-day annual limit for skilled nursing facility care.
Prior review for medical necessity is encouraged for inpatient hospital services, home health care, mental health services, and skilled nursing facility care.	Prior review for medical necessity is encouraged for inpatient hospital services, home health care, mental health services, and skilled nursing facility care.
Pre-approval is required for medical supplies and equipment and for transplant surgery	Pre-approval is required for medical supplies and equipment and for transplant surgery.
No lifetime maximum on benefits except for transplant surgery which has a $350,000 lifetime limit.	No lifetime maximum on benefits, except for a transplant surgery which has a $350,000 lifetime limit.

Updated 01/25/2012

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