LifeWise Health Plan of WA - Online Application

WiseSavings HSA

	WiseSavings (Individual)		WiseSavings (Family)
PCY = Per Calendar Year	Preferred	Non-Preferred	Preferred	Non-Preferred
Annual Deductible PCY (choose one)	$1,750/$3,000 Per Individual		$3,500/$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
Out-of-Pocket Maximum PCY (Includes annual deductible and coinsurance maximum; once met, Preferred Providers covered in full)	$4,250/$4,750	Unlimited	$8,500/$9,500	Unlimited
LIFETIME BENEFIT MAXIMUM	$2,000,000
Covered Services
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	Covered in Full	Covered in Full	Covered in Full
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	Covered in Full	Covered in Full	Covered in Full
Pharmacy - Retail 30-day supply	Not covered. Discount Program available.*		Not covered. Discount Program available.*
Pharmacy - Mail Service 90-day supply
Outpatient Diagnostic X-rays and Lab Services	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Mammography	Dedcutible waived then 20%		Dedcutible waived then 20%
Emergency Room Care Copay waived if direct admit to an inpatient facility	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
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: 20 days PCY; Inpatient: 8 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 130 visits PCY	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
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		Not Covered
Vision - Routine Exam One exam per two calendar years	Not Covered		Not Covered
Vision - Hardware (Per two calendar years)
Mental Health–Outpatient Office Visit 6 visits PCY	Deductible, then 20%	Deductible, then 40%	Deductible, then 20%	Deductible, then 40%
Mental Health–Inpatient Facility Care 6 days PCY
Transplants 12-month waiting period; $250,000 lifetime benefit; Organ & bone marrow	Deductible, then 20%	Not Covered	Deductible, then 20%	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. ** 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. 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.