LifeWise Health Plan of WA - Online Application

WiseChoices Benefits

	WiseChoices 0/20	WiseChoices 0/30	WiseChoices 20	WiseChoices 30	Applies to all WiseChoices plans
PCY = Per Calendar Year	Preferred	Preferred	Preferred	Preferred	Non-Preferred
Annual Deductible PCY (choose one)	$0 Indiv. or $0 Family	$0 Indiv. or $0 Family	$1,000 Indiv. or $3,000 Family	$1,500 Indiv. or $4,500 Family	$3,000 Indiv. or $9,000 Family
Coinsurance (what you pay)	20%	30%	20%	30%	50%
Annual Coinsurance Maximum	$9,500 Indiv. or Family = 3x Indiv.	$9,500 Indiv. or Family = 3x Indiv.	$8,500 Indiv. or Family = 3x Indiv.	$8,500 Indiv. or Family = 3x Indiv.	Unlimited
Out-of-Pocket Maximum PCY (Includes annual deductible and coinsurance maximum; once met, Preferred Providers covered in full)	$9,500 Indiv. or Family = 3x Indiv.	$9,500 Indiv. or Family = 3x Indiv.	$9,500 Indiv. or Family = 3x Indiv.	$10,000 Indiv. or Family = 3x Indiv.	Unlimited
LIFETIME BENEFIT MAXIMUM	$2,000,000
Covered Services	Deductible, coinsurance and copay represent WHAT YOU PAY.
Office Visits and Urgent Care & Naturopathy	Deductible waived $30 Copay	Deductible waived $30 Copay	Deductible waived $30 Copay	Deductible waived $30 Copay	Deductible, then 50%
Preventive Exams (routine medical exam, sports physical & women’s health/well baby exams)
Preventive Screenings (Pap smear, PSA testing, colorectal cancer screening, cholesterol screening & bone density test.)	Covered in Full	Covered in Full	Covered in Full	Covered in Full
Immunizations					Not Covered
Pharmacy-Retail (30-day supply) Brand: $3,000 PCY limit; Generic: unlimited	$10/$45/50%	$10/$45/50%	$10/$45/50%	$10/$45/50%	Preferred network cost + 40%
Pharmacy-Mail Service (90-day supply) Brand: $3,000 PCY limit; Generic: unlimited	$25/$112.50/45%	$25/$112.50/45%	$25/$112.50/45%	$25/$112.50/45%
Outpatient Diagnostic X-rays and Lab Services	Deductible waived then 20%	Deductible waived then 30%	Deductible, then 20%	Deductible, then 30%	Deductible, then 50%
Mammography			Deductible waived then 20%	Deductible waived then 30%
Emergency Room Care - Copay waived if direct admit to an inpatient facility	Deductible waived $100 copay, then 20%	Deductible waived $100 copay, then 30%	$100 copay, then subject to deductible, then 20%	$100 copay, then subject to deductible, then 30%	$100 copay, then subject to deductible, then coinsurance**
Ambulance Transportation - Air: unlimited; Ground: $5,000 PCY limit	Deductible waived then 20%	Deductible waived then 20%	Deductible, then 20%	Deductible, then 30%	Deductible, then coinsurance**
Inpatient & Outpatient Facility Care					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 - ($5,000 PCY)
Spinal and Other Manipulations (12 visits PCY)	Deductible waived $25 Copay	Deductible waived $25 Copay	Deductible waived $25 Copay	Deductible waived $25 Copay	Deductible, then 50%
Acupuncture (12 visits PCY)
Home Health Care (130 visits PCY)	Deductible waived then 20%	Deductible waived then 30%	Deductible, then 20%	Deductible, then 30%	Deductible, then 50%
Skilled Nursing Facility (45 days PCY) Includes room and board, ancillaries & professional fees
Hospice Care (Inpatient: 10 days PCY; Respite: 240 hours PCY)
Maternity Care	Deductible waived then 20%	Deductible waived then 30%	Deductible, then 20%	Deductible, then 30%	Deductible, then 50%
Vision - Routine Exam (One exam per two calendar years)	Covered in full	Covered in full	Covered in full	Covered in full	Covered in full
Vision - Hardware (Per two calendar years)	$200 for frames, lenses & contact lenses	$200 for frames, lenses & contact lenses	$200 for frames, lenses & contact lenses	$200 for frames, lenses & contact lenses	$200 for frames, lenses & contact lenses
Mental Health–Outpatient Office Visit (6 visits PCY)	Deductible waived then $30 copay	Deductible waived then $30 copay	Deductible waived then $30 copay	Deductible waived then $30 copay	Deductible, then 50%
Mental Health–Inpatient Facility Care (6 days PCY)	Deductible waived then 20%	Deductible waived then 30%	Deductible, then 20%	Deductible, then 30%
Transplants (12-month waiting period; $250,000 lifetime benefit) Organ & bone marrow	Deductible waived then 20%	Deductible waived then 30%	Deductible, then 20%	Deductible, then 20%	Not Covered
* In order to validate current eligibility for this discount, the pharmacy will transmit your information to LifeWise Health Plan of Washington, including the details of the prescription to be filled. The information may also be used for other proper purposes. ** 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.