LifeWise Health Plan of WA - Online Application

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Benefit Schedules:
WiseEssentials Rx | WiseEssentials Copay | WiseSimplicity | WiseChoices Prime | WiseSavings
Rate Schedules:
WiseEssentials Rx | WiseEssentials Copay | WiseSimplicity | WiseChoices Prime | WiseSavings

WiseSavings HSA

	WiseSavings (Individual)		WiseSavings (Family)
PCY = Per Calendar Year	Preferred	Non-Preferred	Preferred	Non-Preferred
Annual Deductible PCY (choose one)	$1,820/$3,000 Per Individual		$3,640/$6,000 Per Family*
Coinsurance (what you pay)	20%	40%	20%	40%
Annual Coinsurance Maximum	$2,500/$1,750	Unlimited	$5,000/$3,500	Unlimited
Covered Services (Lifetime maximum $2 million)
Office Visits and Urgent Care & Naturopathy	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Preventive Exams (routine medical exam, sports physical & women’s health/well baby exams)	Covered in Full**	Not covered	Covered in Full**	Not covered
Preventive Screenings (Pap smear, PSA testing, colorectal cancer screening, cholesterol screening & bone density test.)	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Immunizations	Covered in Full**	Not covered	Covered in Full**	Not covered
Pharmacy - Retail	Not covered. Discount Program available.***		Not covered. Discount Program available.***
Pharmacy - Mail Service
Outpatient Diagnostic X-rays and Lab Services	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Mammography	Deductible waived then 20%		Deductible waived then 20%
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; Inpatient: 10 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, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Acupuncture (12 visits PCY)
Home Health Care (120 visits PCY)	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Skilled Nursing Facility (20 days PCY) Includes room and board, ancillaries & professional fees
Hospice Care (Inpatient: 10 days PCY; Respite: 240 hours PCY)
Maternity Care	Not Covered		Not Covered
Vision - Routine Exam	Not Covered		Not Covered
Vision - Hardware
Mental Health–Outpatient Office Visit	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Mental Health–Inpatient Facility Care
Transplants (12-month waiting period; $350,000 lifetime benefit) Organ & bone marrow	Deductible, then 20%	Not Covered	Deductible, then 20%	Not Covered
* Family = Individual + one or more family members. Services for all 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. ** Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance. *** 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.