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LifeWise Health Plan of Oregon
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Index | Exclusions
& Limitations | Locate
Providers | Brochure & Application
Plan Benefits:
Essentials Benefits | Prime
Benefits | HSA-Qualified Benefits
Plan Rates:
Essentials | Prime | HSA-Qualified
Deductible, coinsurance and copay represent what you pay. All coinsurance amounts are based on maximum allowable amounts.
Benefits apply after calendar year deductible is met, unless otherwise noted as “no deductible,” “copay,” or “covered in full.”
| LifeWise Essentials |
Preferred Providers |
Non-Preferred Providers |
Annual Deductible PCY (choose one)
(Family is 3x the individual deductible)* |
$1,000 / $2,500 /
$5,000 |
$7,500 / $10,000 |
2x individual deductible |
| Coinsurance1 (what you pay) |
35% |
40% |
50% |
Annual Coinsurance Maximum
(family = 2x individual)2 |
$7,500 |
$7,500 |
$15,000 |
| Lifetime Maximum |
$2,000,000 |
| Covered Services |
Preferred Providers |
Non-Preferred Providers |
| Preventive Care
|
Preventive Care Exams
(routine medical exam, sports
physical and women’s health exams/well baby) |
$35 Copay on first 3 visits PCY3 |
$40 Copay on first 3 visits PCY4 |
Deductible, then 50% |
Preventive Screenings
(includes Pap smear, PSA
testing, home colon cancer screening, cholesterol
screening and bone density test) |
Covered in full4 |
| Immunizations |
| Professional Care
|
| Office Visit including Urgent Care2 |
$35 Copay on first 3 visits PCY3 |
$40 Copay on first 3 visits PCY4 |
Deductible, then 50% |
| Other Outpatient and Inpatient Professional Service |
Deductible, then 35% |
Deductible, then 40% |
| Alternative Care
|
Chiropractic
12 visits PCY
(visits
shared with Acupuncture) |
Deductible waived, $35 Copay |
Deductible waived, $40 Copay |
Deductible, then 50% |
Acupuncture
12 visits PCY
(visits shared with Chiropractic) |
| Naturopathy3 |
$35 Copay on first 3 visits PCY3 |
$40 Copay on first 3 visits PCY4 |
| Diagnostic Services
|
Outpatient Diagnostic Imaging and Lab Services
Basic Imaging/Lab Services: |
Deductible, then 35% |
Deductible, then 40% |
Deductible, then 50% |
Outpatient Diagnostic Imaging and Lab Services
Complex Imaging (PET, CT, MRI, & MRA): |
Deductible, then 50% |
| Mammography |
Covered in full5 |
| Pharmacy
|
| Retail Pharmacy (30-day supply) |
$20 Generics only |
Not covered |
| Mail Service Pharmacy (90-day supply) |
$60 Generics only |
| Emergency Care
|
Emergency Room Care
(copay waived if direct admit to an inpatient facility) |
$150 Copay, then subject to preferred provider deductible, then preferred provider coinsurance |
Ambulance Transportation
Air (unlimited); Ground ($5,000 PCY limit) |
Deductible, then 35% |
Deductible, then 40% |
Preferred provider deductible, then preferred provider coinsurance |
| Facility Care
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| Inpatient Facility Care |
Deductible, then 35% |
Deductible, then 40% |
Deductible, then 50% |
| Outpatient Facility Care |
| Skilled Nursing Facility 45 days PCY; includes room and
board, ancillaries and professional fees |
| Maternity
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| Maternity Care |
Prenatal & Postnatal Care: Deductible, then coinsurance Routine Delivery†: Deductible, then 50% |
Deductible, then 50% |
| Vision Care
|
Routine Vision Exam
1 exam PCY |
Deductible waived, $35 Copay |
Deductible waived, $40 Copay |
Preferred provider deductible, then preferred provider coinsurance |
| Other Services
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| Home Medical Equipment & Supplies $5,000 PCY |
Deductible, then 40% |
Deductible, then 40% |
Deductible, then 50% |
| Home Health Care 130 visits PCY |
| Hospice Care Inpatient: 10 days, Respite: 240 hours
per 6 months lifetime maximum |
| Rehabilitation (includes Physical, Occupational & Speech
Therapy, Cardiac & Pulmonary Rehab; & Chronic Pain)
Outpatient: 20 visits PCY; Inpatient: 8 days PCY |
| Transplants (Organ & Bone Marrow) 24-month
waiting period; $250,000 Lifetime Benefit |
| Alcohol Dependency Treatment |
This optional benefit is available at an additional cost. It is limited to $4,500 in any 24 consecutive months |
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PCY = Per Calendar Year
1 All coinsurance amounts are the member’s percentage of maximum allowable amounts after deductible
2 Does not include deductible
3 Deductible waived, you pay $35 on first 3 visits PCY; additional
visits subject to deductible, then 35%. Office visits, preventive exams and naturopathy are shared
4 Deductible waived, you pay $40 on first 3 visits PCY; additional visits subject to deductible,then
40%. Office visits, preventive exams and naturopathy are shared
5 Benefits provided at 100% of maximum allowable amounts; not subject to deductible or coinsurance
† Complications of pregnancy
are covered at deductible, then coinsurance
Note: Prosthetics and orthotic devices
are a covered service on LifeWise plans
and are not subject to a PCY limit.
This is only a summary of major benefits. It is not a contract. |
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