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LifeWise Health Plan of Oregon
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Index | Exclusions
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Plan Benefits:
WiseEssentials Benefits | WiseEssentials 50 Benefits | WiseChoices
Benefits | WiseSavings
Benefits
Plan Rates:
WiseEssentials | WiseEssentials 50 | WiseChoices | WiseSavings
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.”
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WiseSavings (HSA Eligible) |
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Preferred Providers |
Non-Preferred & extended providers |
| Annual Deductible PCY (choose one) |
Individual: $3,000
Family: $6,000* |
| Coinsurance1 (what you pay) |
20% |
50% |
| Annual Coinsurance Maximum2 |
Individual: $2,000
Family: $4,000 |
Unlimited |
| Lifetime Maximum |
$2,000,000 |
| Covered Services |
Preferred Providers |
Non-Preferred & extended providers |
| Preventive Care
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Preventive Care Exams
(routine medical exam, sports
physical and women’s health exams/well baby) |
DEDUCTIBLE WAIVED,
you pay 20% |
Deductible, then 50% |
Preventive Screenings
(includes Pap smear, PSA
testing, home colon cancer screening, cholesterol
screening and bone density test) |
Covered in full3 |
| Immunizations |
| Professional Care
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| Office Visit including Urgent Care |
Deductible, then 20% |
Deductible, then 50% |
| Other Outpatient and Inpatient Professional Services |
| Alternative Care
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Chiropractic
12 visits PCY
(visits
shared with Acupuncture) |
Deductible, then 20% |
Deductible, then 50% |
Acupuncture
12 visits PCY
(visits shared with Chiropractic) |
| Naturopathy |
| Diagnostic Services
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| Outpatient Diagnostic Imaging and Lab Services |
Deductible, then 20% |
Deductible, then 50% |
| Mammography |
Covered in full3 |
| Pharmacy
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| Retail Pharmacy (30-day supply) |
Deductible, then 50%;
Certain preventive generic drugs are reimbursed at 100% |
| Mail Service Pharmacy (90-day supply) |
Deductible, then 45%;
Certain preventive generic drugs are reimbursed at 100% |
| Emergency Care
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| Emergency Room Care |
Deductible, then 20% |
Ambulance Transportation
Air (unlimited); Ground ($5,000 PCY limit) |
| Facility Care
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| Inpatient Facility Care |
Deductible, then 20% |
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 |
Deductible, then 20% |
Deductible, then 50% |
| Vision Care
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| Routine Vision Exam |
Not Covered |
| Vision Hardware |
| Other Services
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| Supplies, Equipment and Prosthetics $5,000 PCY |
Deductible, then 20% |
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) 12-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 Benefits provided at 100% of maximum allowable amounts; not subject to deductible or coinsurance
* Services for all family members covered under the same HSA-qualified plan get applied to the same deductible.
The family deductible must be met before services are covered for any enrolled family members.
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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HealthNet
Oregon 