LifeWise Health Plan of WA - Online Application

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

WiseSavings HSA

	WiseSavings (Individual)		WiseSavings (Family)2
PCY = Per Calendar Year	Preferred	Non-Preferred	Preferred	Non-Preferred
Annual Deductible PCY (choose one)	$1,840/$3,000 Per Individual		$3,680/$6,000 Per Family2
Coinsurance (what you pay)	20%	40%	20%	40%
Annual Coinsurance Maximum	$2,500/$1,750	Unlimited	$5,000/$3,500	Unlimited
Covered Services (calendar year maximum $2 million)
Office Visits includes Urgent Care & Naturopathy	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Preventive Exams	Covered in Full1	Not covered	Covered in Full1	Not covered
Preventive Screenings3 includes mammograms	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Immunizations	Covered in Full1	Not covered	Covered in Full1	Not covered
Pharmacy - Retail (30-day supply)	Not covered; pharmacy discount program available.		Not covered; pharmacy discount program available.
Pharmacy - Mail Order (90-day supply)
Outpatient Diagnostic X-rays and Lab Services	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Emergency Room Care	Deductible, then 20%	Deductible, then 20%	Deductible, then 20%	Deductible, then 20%
Ambulance Transportation Air: unlimited; Ground: $5,000 PCY limit
Inpatient & Outpatient Facility Care	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Rehabilitation (Outpatient: 15 visits PCY only Inpatient: 10 days PCY only) Physical, occupational, massage & speech therapy; cardiac & pulmonary rehabilitation	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Durable Medical Equipment and Prosthetics
Maternity Care	Not Covered		Not Covered
Vision - Routine Exam	Not Covered		Not Covered
Vision - Hardware
Mental Health–Outpatient	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Mental Health–Inpatient
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)
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.. The Select Drug List helps reduce prescription drug costs by excluding select medications that have over-the-counter (OTC) alternatives available and brand name drugs that have generics available. Excluded drug classes because of ample OTC availability include cough and cold, antihistamines & heartburn/acid reflux medications. 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.