Lifewise Health Plan of Oregon

Deductible, coinsurance and copay represent what you pay. All coinsurance amounts are based on maximum allowable amounts.  Benefits apply after calendar year deductible is met, unless otherwise noted as "no deductible," "copay," or "covered in full."

LifeWise HSA-Qualified Benefits
  Preferred Provider Non-Preferred Provider
Annual Deductible PCY(choose one) Individual: $3,000
Family: $6,000*		 Individual: $5,950
Family: $11,900*		 Shared with preferred provider deductible
Coinsurance1 (what you pay) 25% 0% 50%
Annual Coinsurance Maximum2 $2,950 Individual $5,900 Family $0 $5,900 Individual $11,800 Family2
Lifetime Maximum $2,000,000
Covered Services Preferred Providers Non-Preferred & extended providers
Preventive Care
Preventive Care Exams
(routine medical exam, sports physical and women’s health exams/well baby)		 Deductible waived, then 25% Deductible waived, then covered in full Deductible, then 50%
Preventive Screenings
(includes Pap smear, PSA testing, home colon cancer screening, cholesterol screening and bone density test)		 Covered in full3 Covered in full3
Immunizations
Professional Care
Office Visit including Urgent Care Deductible, then 25% Deductible, then covered in full Deductible, then 50%
Other Outpatient and Inpatient Professional Services
Alternative Care
Chiropractic
12 visits PCY
(visits shared with Acupuncture)		 Deductible, then 25% Deductible, then covered in full Deductible, then 50%
Acupuncture
12 visits PCY
(visits shared with Chiropractic)
Naturopathy
Diagnostic Services
Outpatient Diagnostic Imaging and Lab Services Deductible, then 25% Deductible, then covered in full Deductible, then 50%
Mammography Covered in full3 Covered in full3
Pharmacy
Retail Pharmacy - Generics4 (30-day supply) Deductible, then 25%
($5,000 PCY limit) 		Deductible, then covered in full
($5,000 PCY limit) 		Not Covered
Mail Service Pharmacy - Generics4 (90-day supply)
Emergency Care
Emergency Room Care Deductible, then 25% Deductible, then covered in full Preferred provider deductible, then preferred provider coinsurance
Ambulance Transportation
Air (unlimited); Ground ($5,000 PCY limit)
Facility Care
Inpatient Facility Care Deductible, then 25% Deductible, then covered in full Deductible, then 50%
Outpatient Facility Care
Skilled Nursing Facility 45 days PCY; includes room and board, ancillaries and professional fees
Maternity
Maternity Care Deductible, then 25% Deductible, then covered in full Deductible, then 50%
Vision Care
Routine Vision Exam
1 exam PCY 		Deductible, then 25% Deductible, then covered in full Preferred provider deductible, then preferred provider coinsurance
Other Services
Supplies, Equipment and Prosthetics $5,000 PCY Deductible, then 25% Deductible, then covered in full Deductible, then 50%
Home Health Care 130 visits PCY
Hospice Care Inpatient: 10 days, Respite: 240 hours per 6 months lifetime maximum
Rehabilitation (includes Physical, Occupational & Speech Therapy, Cardiac & Pulmonary Rehab; & Chronic Pain) Outpatient: 20 visits PCY; Inpatient: 8 days PCY
Transplants (Organ & Bone Marrow) 12-month waiting period; $250,000 Lifetime Benefit
Alcohol Dependency Treatment This optional benefit is available at an additional cost. It is limited to $4,500 in any 24 consecutive months

PCY = Per Calendar Year
1 All coinsurance amounts are the member’s percentage of maximum allowable amounts after deductible
2 Does not include deductible
3 Benefits provided at 100% of maximum allowable amounts; not subject to deductible or coinsurance
4 Certain preventive generic drugs are reimbursed at 100%

* Services for all family members covered under the same HSA-qualified plan get applied to the same deductible. The family deductible must be met before services are covered for any enrolled family members.

Note:Prosthetics and orthotic devices are a covered service on LifeWise plans and are not subject to a PCY limit.

This is only a summary of major benefits. It is not a contract.