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WiseSimplicity Benefits |
| PCY = Per Calendar Year |
Preferred |
Non-Preferred |
| Annual Deductible PCY |
$10,000 |
$20,000 |
| Coinsurance (what you pay) |
0% |
50% |
| Annual Coinsurance Maximum1 |
$0 |
Unlimited |
Covered Services (calendar year maximum $2 million) |
Office Visits
Includes visits to your doctor, specialist,
naturopath, or urgent care center |
Deductible, then covered in full |
Deductible, then 50% |
Preventive Exams
Includes physicals, women's health exams, and well-baby exams.
|
Covered in full
(1 exam PCY; well-baby exams are unlimited) |
Preventive Screenings
Includes mammograms, colonoscopies and vaccines |
Covered in full |
| Immunizations |
Not Covered |
| Pharmacy - Retail (30-day supply) |
Not covered;
pharmacy discount program available. |
| Pharmacy - Mail Order (90-day supply) |
Spinal & Other Manipulations
12 visits PCY |
Deductible, then covered in full |
Deductible, then 50% |
Acupuncture
12 visits PCY |
Emergency Room Care
Copay waived if direct admit to an inpatient facility |
$100 copay, then subject to Deductible, then covered in full |
$100 copay, then subject to Deductible, then covered in full |
Ambulance Transportation
Air: unlimited; Ground: $5,000 PCY limit |
Deductible, then covered in full |
Deductible, then covered in full |
Outpatient Diagnostic Imaging & Labs
Includes x-rays, MRIs, CAT scans |
Deductible, then covered in full |
Deductible, then 50% |
Inpatient & Outpatient Facility Care
Includes hospital care & professional services |
Deductible, then covered in full |
Deductible, then 50% |
Rehabilitation
(Outpatient: 20 days PCY; Inpatient: 8 days PCY) Physical, occupational, massage & speech therapy; cardiac &
pulmonary rehabilitation |
Deductible, then covered in full |
| Mental Health–Outpatient |
Deductible, then covered in full |
Deductible, then 50% |
| Mental Health–Inpatient |
| Maternity Care |
Not Covered |
| Durable Medical Equipment and Prosthetics |
Not Covered |
Not Covered |
Vision - Routine Exam
One exam per two calendar years |
Not Covered |
Vision - Hardware
Per two calendar years |
- After paying your deductible and coinsurance maximum, LifeWise will pay 100% of the negotiated rate for services from preferred providers.
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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