General exclusions and limitations
Some services may require prior authorization. Certain services must be prior authorized in writing before you receive care. If you do not request prior authorization when required, you will be subject to a penalty of 50% of the maximum allowable amount, up to a maximum of $500 per occurrence. Additionally, benefit plans typically have exclusions and limitations - what the plans do not cover. The following are general exclusions and limitations for the LifeWise benefit plans. For a complete list of exclusions and limitations, please visit lifewiseor.com.
What is not covered?
Benefits are not provided for services, treatment, surgery, drugs or supplies for any of the following:
- Alcohol dependency treatment services (unless optional alcohol endorsement is purchased)
- Allergy and testing injections (WiseValue Plus and WiseValue Plus Rx plan only)
- Chemical (drug addiction) dependency
- Conditions arising from acts of war or service in the military
- Cosmetic or reconstructive services, except as specifically provided in the contract
- Drugs from a non-preferred pharmacy
- Experimental or investigative services
- Mental health
- Obesity/morbid obesity, including surgery, drugs, foods and exercise programs.
- Orthognathic surgery (unless it meets medical criteria and as required by ORS 743a.148)
- Over-the-counter or non-prescription drugs
- Services determined not to be medically necessary
- Services in excess of specified benefit maximums
- Services payable by other types of insurance coverage
- Services received when you are not covered by this program
- Sexual dysfunction
- Sterilization reversal
- Treatment for work-related conditions for which benefits are provided by Workers’ Compensation or similar coverage
- Treatment of temporomandibular joint (TMJ) disorder
- Vision hardware (except for WiseOptimum plan)
LifeWise individual health benefit plans include a six-month pre-existing conditions waiting period. Benefits for any pre-existing conditions will not be provided for the first six months following a member's effective date of coverage. Pre-existing conditions means any medical condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to a member's effective date of coverage or actual enrollment in the plan. These waiting periods are waived for children under 19.
Organ Transplant Benefit Exclusion Period
A benefit exclusion period is a time when the plan does not cover certain treatment or services. LifeWise individual health benefit plans have a 24-month benefit exclusion period for organ transplant services. This period begins on the date your coverage starts.
If you had healthcare coverage that ended less than 63 days before you enrolled in a LifeWise plan, it is “creditable coverage.” LifeWise will reduce your waiting periods by the amount of creditable coverage you have.
Creditable coverage includes:
- Any group healthcare coverage (including the Federal Employees Health Benefits Plan and the Peace Corps)
- Individual healthcare coverage (including student healthcare coverage)
- Medicare or Medicaid
- Indian Health Service or tribal organization coverage
- State high-risk pool coverage
- A public health plan as defined in 42 U.S.C. 300gg, as amended and in effect on July 1, 1997.
Charges over the maximum allowable amount
You may be responsible for charges that exceed the maximum allowable amount for covered services provided by non-preferred providers.