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WiseEssentials Copay Benefits |
| PCY = Per Calendar Year |
Preferred |
Non-Preferred |
Annual Deductible PCY
(choose one; no family deductible) |
$5,000/$7,500 |
$10,000/$15,000 |
| Coinsurance (what you pay) |
25% |
50% |
| Annual Coinsurance Maximum |
$5,000 |
Unlimited |
Covered Services (calendar year maximum $2 million) |
Office Visits
includes Urgent Care & Naturopathy |
Deductible waived
on first 3 visits PCY, you pay $25 copay only; additional visits subject to deductible, then 25% |
Deductible, then 50% |
| Preventive Exams |
Covered in full1 |
Preventive Screenings3
includes mammograms |
| Immunizations |
Not Covered |
| Pharmacy - Retail (30-day supply) |
Not covered;
pharmacy discount program available. |
| Pharmacy - Mail Order (90-day supply) |
| Outpatient Diagnostic Imaging & Lab Services |
Deductible, then 25% |
Deductible, then 50% |
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% |
Alternative Care
Spinal Manipulations - 12 visits PCY Acupuncture - 12 visits PCY |
Deductible waived,
$25 Copay |
Deductible, then 50% |
| 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 |
Not Covered |
Not Covered |
| Mental Health–Outpatient |
Deductible waived
on first 3 visits PCY, you pay $25 copay only; additional visits subject to deductible, then 25% |
Deductible, then 50% |
| Mental Health–Inpatient |
Deductible, then 25% |
| Maternity Care |
Not Covered |
| Vision - Routine Exam (One exam per two calendar years) |
Not Covered |
| Vision - Hardware (Per two calendar years) |
| The following are included in your LifeWise plan: |
Preventive Exams – covered in full within network3
- Routine physicals and physicals for school, sports and employment
- Women’s or men’s annual exams
- Well-baby and newborn exams
- Preventive immunizations (includes HPV vaccine)
Preventive Screenings – covered in full within network3
- Cancer Screenings: Cervical (PAP), prostate (PSA), mammograms and colonoscopies.
- Infectious Disease Screenings: Chlamydia antibody and hepatitis antigen screenings
- Metabolic, Nutrition and Endocrine Screenings: Glucose testing (blood sugar) and anemia (iron deficiency) screenings
- Heart and Vascular Disease Screenings: Lipid panel/lipoprotein/high cholesterol screenings and high blood pressure testing
- Musculoskeletal Disorder Screening: Bone density screening (osteoporosis)
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- Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance.
- Family = Individual plus one or more family members. Services for family members covered under the same HSA-qualified plan are applied to the family deductible. The family deductible must be
met before services are covered for any enrolled family members.
- 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..
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.
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