What is not covered?

Benefits are not provided for services, treatment, surgery, drugs or supplies for any of the following:

• Alcohol dependency treatment services (unless optional alcohol endorsement is purchased)
• Allergy and testing injections (on Essentials plan only)
• Biofeedback
• Chemical (drug addition) dependency
• Conditions arising from acts of war or service in the military
• Cosmetic or reconstructive services, except as specifically provided in the contract
• Dental services
• Experimental or investigative services
• Infertility
• Mental health
• Obesity/morbid obesity
• Orthognathic surgery (unless it meets medical criteria and as required by ORS 743.706)
• Out-of-network drug coverage
• Over-the-counter or non-prescription drugs
• Services determined by us to be medically unnecessary
• Services in excess of specified benefit maximums
• Services payable by other types of insurance coverage
• Services received when you are not covered by this program
• Sexual dysfunction
• Sterilization reversal
• Treatment for work-related conditions for which benefits are provided by Workers’ Compensation or similar coverage
• Treatment of temporomandibular joint (TMJ) disorder
• Vision hardware

Charges over the maximum allowable amount

You may be responsible for charges that exceed the maximum allowable amount for covered services provided by non-preferred providers.

Waiting periods

Pre-existing Condition—LifeWise individual health benefit plans include a six-month pre-existing conditions waiting period. Benefits for any pre-existing conditions will not be provided for the first six months following a member’s effective date of coverage. Pre-existing conditions means any medical condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to a member’s effective date of coverage or actual enrollment in the plan.

Organ Transplant Benefit Exclusion Period—LifeWise individual health benefit plans include a 24-month benefit exclusion period for organ transplant services. The benefit exclusion period begins on your effective date of coverage under the LifeWise policy. Benefits for organ transplant services will not be covered until you have been covered under the LifeWise policy for 24 consecutive months.

Creditable Coverage

LifeWise will reduce the duration of the pre-existing condition provision and/or the organ transplant benefit exclusion period by the amount of creditable coverage if the creditable coverage is in effect on the date of enrollment or did not terminate more than 63 days prior to enrollment in a LifeWise health benefit plan. A period of creditable coverage will not be credited if there was more than a 63-day break in coverage.

Creditable coverage includes any group healthcare coverage (including the Federal Employees Health Benefits Plan and the Peace Corps), individual healthcare coverage (including student healthcare coverage), Medicare, Medicaid, TRICARE, Indian Health Service or tribal organization coverage, state high-risk pool coverage, or a public health plan as defined in 42 U.S.C. 300gg, as amended and in effect on July 1, 1997.