Lifewise Health Plan of Washington

Lifewise WiseAdvantage Benefits
PCY = Per Calendar Year	Preferred	Non-Preferred
Annual Deductible PCY (choose one)	Individual: $1,800 Family: $5,400	Individual: $3,600 Family: $10,800
Coinsurance (what you pay)	35%	50%
Annual Coinsurance Maximum	Individual: $6,500 Family: 3x Individual	Unlimited
Covered Services (calendar year maximum $2 million)
Office Visits includes Urgent Care & Naturopathy	Deductible waived $30 Copay	Deductible, then 50%
Preventive Exams¹ Routine medical exam, sports physical & women's health/well baby exams	Covered in Full²
Preventive Screenings PAP smear, PSA testing, mammography, colonoscopies, cancer screening, cholesterol screening
Immunizations		Not Covered
Pharmacy - Retail (30-day supply)	Preferred Generics/Non-Preferred Generic Retail³: $15/50% Mail Order³: $45/50%	Not Covered
Pharmacy - Mail Order (90-day supply)		Not Covered
Outpatient Diagnostic Imaging & Lab Service	Deductible, then 35%	Deductible, then 50%
Emergency Room Care Copay waived if directly admited to an inpatient facility	$100 copay, then subject to deductible, then 35%	$100 copay, then subject to deductible, then 35%⁴
Ambulance Transportation Air: unlimited; Ground: $5,000 PCY limit	Deductible, then 35%	Deductible, then 35%
Inpatient & Outpatient Facility Care	Deductible, then 35%	Deductible, then 50%
Rehabilitation (Outpatient: 20 days PCY; Inpatient: 8 days PCY) Physical, occupational, massage & speech therapy; cardiac & pulmonary rehabilitation
Durable Medical Equipment and Prosthetics
Spinal & Other Manipulations 12 visits PCY	Deductible waived $25 Copay	Deductible, then 50%
Acupuncture 12 visits PCY	Deductible waived $25 Copay	Deductible, then 50%
Home Health Care 130 visits PCY	Deductible, then 35%	Deductible, then 50%
Skilled Nursing Facility 45 days PCY - Includes room & board, ancillaries & professional fee
Hospice Care Inpatient: 10 days PCY; Respite: 240 hours PCY
Maternity Care	Deductible, then 35%	Deductible, then 50%
Vision - Routine Exam (One exam per two calendar years)	Covered in Full	Covered in Full
Vision - Hardware (Per two calendar years)	$200 for frames, lenses & contact lenses	$200 for frames, lenses & contact lenses
Mental Health–Outpatient	Deductible waived $30 Copay	Deductible, then 50%
Mental Health–Inpatient	Deductible, then 35%	Deductible, then 50%
Transplants 12-month waiting period; Organ & Bone Marrow	Deductible, then 35%	Deductible, then 50%
This plan is "non-grandfathered" under federal healthcare reform legislation. A full list of preventive screenings, tests and other preventive services, is available on lifewisewa.com. You can receive these preventive services covered in full if you use preferred providers and are within the frequency, age, risk and gender guidelines outlined in the list. Benefits provided at 100% of allowable charges; not subject to deductible, copay or coinsurance. Brand: Pharmacy discount program available. Unlike services received at other non-preferred providers, this service is subject to the preferred provider deductible and coinsurance. Note: Deductible, coinsurance and copay represent what you pay. Benefits apply after calendar year deductible is met, unless otherwise noted as “Deductible Waived,” “Copay” or “Covered in Full.” All coinsurance amounts are based on allowable charges. Balance billing may apply if a provider is not contracted with LifeWise Health Plan of Washington. Please note that this is a general summary. Your individual health plan contract will describe the actual terms, conditions and exclusions of coverage.