LifeWise Health Plan of WA - Online Application

WiseEssentials Benefits

	WiseEssentials Benefits
PCY = Per Calendar Year	Preferred	Non-Preferred
Annual Deductible PCY (choose one)	$1,750/$,2,500/$3,500	$3,500/$5,000/$7,000
Coinsurance (what you pay)	25%	50%
Annual Coinsurance Maximum	$5,000	Unlimited
Out-of-Pocket Maximum PCY (Includes annual deductible and coinsurance maximum; once met, Preferred Providers covered in full)	$6,750/$7,500/$8,500	Unlimited
LIFETIME BENEFIT MAXIMUM	$2,000,000
Covered Services
Office Visits and Urgent Care & Naturopathy	Deductible waived on first 6 visits subject to 25%; subsequent visits subject to deductible and 25%	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
Immunizations	Not Covered	Not Covered
Pharmacy - Retail	Not covered. Discount Program available.*
Pharmacy - Mail Service
Outpatient Diagnostic X-rays and Lab Services	Dedcutible waived then 25% for $1,750 deductible plan only	Deductible, then 50%
	Deductible, then 25% for all others
Mammography	Dedcutible waived then 25%
Emergency Room Care - Copay waived if direct admit to an inpatient facility	$100 copay, then subject to deductible, then 25%	$100 copay, then subject to deductible, then 25%**
Ambulance Transportation - Air: unlimited; Ground: $5,000 PCY limit	Deductible, then 25%	Deductible, then 25%**
Inpatient & Outpatient Facility Care	Deductible, then 25%	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)	Not Covered	Not Covered
Spinal and Other Manipulations (12 visits PCY)	Dedcutible waived $25 Copay	Deductible, then 50%
Acupuncture (12 visits PCY)
Home Health Care (130 visits PCY)	Deductible, then 25%	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	Not Covered
Vision - Routine Exam (One exam per two calendar years)	Not Covered
Vision - Hardware (Per two calendar years)
Mental Health–Outpatient Office Visit (6 visits PCY)	Deductible waived then 25%	Deductible, then 50%
Mental Health–Inpatient Facility Care (6 days PCY)	Deductible, then 25%
Transplants (12-month waiting period; $250,000 lifetime benefit) Organ & bone marrow	Deductible, then 25%	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.