LifeWise Health Plan of WA - Online Application

Index | Optional Dental | Exclusions & Limitations | Provider | Download Application

Benefit Schedules:
WiseEssentials Rx | WiseEssentials Copay | WiseSimplicity | WiseAdvantage | WiseSavings
Rate Schedules:
WiseEssentials Rx | WiseEssentials Copay | WiseSimplicity | WiseAdvantage | WiseSavings

WiseEssentials Rx Benefits

	WiseEssentials Rx Benefits
PCY = Per Calendar Year	Preferred	Non-Preferred
Annual Deductible PCY (choose one)	$1,880/$,2,500/$3,500	$3,760/$5,000/$7,000
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 6 visits subject to 25%; subsequent visits subject to deductible and 25%	Deductible, then 50%
Preventive Exams3 Routine medical exam, sports physical & women's health/well baby exam
Preventive Screenings PAP smear, PSA testing, mammography, colonoscopies, cancer screening, cholesterol screening	Covered in Full2
Immunizations		Not Covered
Pharmacy - Retail (30-day supply)	Generics only Retail: $15	Not Covered
Pharmacy - Mail Order (90-day supply)	Generics only Mail Order: $40	Not Covered
Outpatient Diagnostic Imaging & Lab Services	Deductible waived then 25% for $1,880 deductible plan only	Deductible, then 50%
	Deductible, then 25% for all others
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%
Outpatient & Inpatient 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
Spinal & Other Manipulations 12 visits PCY	Deductible, then 25%	Deductible, then 50%
Acupuncture 12 visits PCY	Deductible, then 25%	Deductible, then 50%
Home Health Care 130 visits PCY	Deductible, then 25%	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	Not Covered
Vision - Routine Exam (One exam per two calendar years)	Not Covered
Vision - Hardware (Per two calendar years)
Mental Health–Outpatient	Deductible waived on first 6 visits PCY, you pay 25%; additional visits subject to deductible, then 25%	Deductible, then 50%
Mental Health–Inpatient	Deductible, then 25%
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. 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.