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."

WiseHSA Plan Benefits
MEDICAL BENEFITS PREFERRED PROVIDERS NON-PREFERRED PROVIDERS
Annual Deductible PCY (choose one)
(Family is 3x the individual deductible)		 $3,000 Individual
$6,000 Family1		 $5,950 Individual
$11,900 Family1		 $3,000 Individual
$6,000 Family1		 $5,950 Individual
$11,900 Family1
Coinsurance2 (what you pay) 50% 0% 50%
Annual Coinsurance Maximum3 (family = 2x individual) $2,000 Individual
$4,000 Family		 $0 $4,000 Individual
$8,000 Family		 $11,900 Individual
$23,800 Family
Calendar Year Maximum $2,000,000
COVERED SERVICES PREFERRED PROVIDERS NON-PREFERRED PROVIDERS
PREVENTIVE CARE
Preventive Care Exams
(routine medical exam, sports physical and women's health exams/well baby)		 Covered in full4 Covered in full4 Deductible, then 50%
Preventive Screenings5
(includes mammograms, colonoscopies, PAP & PSA screenings)
Immunizations
(includes HPV vaccine)
PROFESSIONAL CARE
Office Visit including Urgent Care, Specialists and Naturopathy Deductible, then 50% Deductible, then covered in full Deductible, then 50%
Other Outpatient and Inpatient Professional Services
ALTERNATIVE CARE
Chiropractic & Acupuncture
12 visits each PCY		 Deductible, then 50% Deductible, then covered in full Deductible, then 50%
DIAGNOSTIC SERVICES
Outpatient Diagnostic Imaging and Lab Services Deductible, then 50% Deductible, then covered in full Deductible, then 50%
PHARMACY
Retail: 30-day supply
Mail Order: 90-day supply

Select Drug List6
Preventive generic drugs: Covered in full		 Generics & Brand:
Deductible, then 50%

Select Drug List6		 Generics:
Deductible, then covered in full

Brand: Not covered

 Not covered
EMERGENCY CARE
Emergency Room Care
(copay waived if direct admit to an inpatient facility)		 Deductible, then 50% Deductible, then covered in full Preferred provider deductible, then preferred provider coinsurance
Ambulance Transportation
Air (unlimited); Ground ($5,000 PCY limit)
FACILITY CARE
Inpatient & Outpatient Facility Care Deductible, then 50% Deductible, then covered in full Deductible, then 50%
Skilled Nursing Facility
45 days PCY; includes room and board, ancillaries and professional fees
MATERNITY
Maternity Care
(includes professional and facility care)		 Deductible, then 50% Deductible, then covered in full Deductible, then 50%
VISION CARE
Routine Vision Exam
1 exam PCY		 Deductible, then 50% Deductible, then covered in full Deductible, then 50%
Hearing Hardware
$5,000 in a consecutive 48-month period; age limits apply		 Preferred provider deductible, then preferred provider coinsurance
OTHER SERVICES
Home Medical Equipment and Supplies Deductible, then 50% Deductible, then covered in full Deductible, then 50%
Home Health Care
130 visits PCY
Hospice Care
Inpatient: 10 days
Outpatient Respite: 240 hours - per 6 months lifetime maximum
Rehabilitation
Outpatient: 20 visits PCY
Inpatient: 8 days PCY
(Includes Physical, Occupational & Speech Therapy, Cardiac & Pulmonary Rehab; & Chronic Pain)
Transplants (Organ & Bone Marrow)
24-month waiting period; Donor and travel limits apply
Alcohol Dependency Treatment This optional benefit is available at an additional cost.

PCY= Per Calendar Year

Deductible, coinsurance and copay represent what you pay. All covered services are based on maximum allowable amounts. Benefits apply after you meet your calendar year deductible unless you see "no deductible," "copay," or "covered in full."

  1. Family equals individual plus one or more family members. 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.
  2. A member's cost for covered services after deductible
  3. Does not include deductible
  4. Benefits provided at 100% of maximum allowable amounts. This is not subject to deductible or coinsurance
  5. A full list of preventive screenings, tests and other preventive services, is available on lifewiseor.com. You can receive these preventive services covered in full if you use preferred providers and are within the frequency, age, risk and gender guidelines outlined in the list.
  6. Medicines with many over-the-counter (OTC) alternatives and brand name drugs with generic options are not on the Select Drug List. These medicines are not covered. Examples include cough and cold, antihistamines & heartburn/acid reflux medicines.

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