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Lifewise Health Plan of Oregon - Electronic Application
Index | Exclusions
& Limitations | Locate
Providers | Brochure & Application
Plan Benefits:
Essentials Benefits | Prime
Benefits | HSA-Qualified Benefits
Plan Rates:
Essentials | Prime | HSA-Qualified
Deductible and coinsurance represent what you pay. Benefits apply after calendar year deductible is met, unless otherwise noted as “deductible waived,” or “covered in full.”
| LifeWise HSA-Qualified |
Preferred Providers |
Non-Preferred Providers |
| Annual Deductible PCY |
$3,000 Individual $6,000 Family1 |
$5,950 Individual $11,900 Family1 |
Shared with preferred provider deductible |
| Coinsurance (what you pay) |
25% |
0% |
50% |
| Annual Coinsurance Maximum2 |
$2,950 Individual $5,900 Family |
$0 |
$5,900 Individual $11,800 Family |
| Calendar Year Maximum |
$1,000,000 |
| Covered Services |
Preferred Providers |
Non-Preferred Providers |
| Office Visits, Urgent Care & Naturopathy |
Deductible, then 25% |
Deductible, then covered in full |
Shared with preferred provider deductible |
Preventive Care Exams
|
Covered in full3 |
Covered in full3 |
Deductible, then 50% |
Preventive Screenings
(includes mammograms, colonoscopies, PAP & PSA screenings) |
| Immunizations (includes HPV vaccine)4 |
Alternative Care
(Chiropractic & Acupuncture—12 shared visits PCY) |
Deductible, then 25% |
Deductible, then covered in full |
Preferred provider deductible, then preferred provider coinsurance |
Emergency Room Care
(copay waived if direct admit to an inpatient facility) |
Ambulance Transportation
(Air: Unlimited; Ground $5,000 PCY limit) |
Outpatient Diagnostic Imaging & Lab Services
(X-Ray & Lab Services) |
| Inpatient/Outpatient Facility Care |
Deductible, then 25% |
Deductible, then covered in full |
Deductible, then 50% |
| Maternity Care |
Vision & Hearing Care—Routine Exam
(1 exam PCY) |
Pharmacy (Retail: 30 day supply; Mail Order: 90 day supply)
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| Generics |
Deductible, then 25%
Certain preventive generic drugs are covered at 100%
|
Deductible, then covered in full
Certain preventive generic drugs are covered at 100%
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Not covered |
| Preferred Brand & Non-Preferred Brand |
Not covered |
Not covered |
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PCY = Per Calendar Year
- Family = Individual plus 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.
- Does not include deductible.
- Benefits provided at 100% of maximum allowable amount; not subject to deductible or coinsurance.
- 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.
Preventive exams—we’re here to make staying healthy easier. The following exams are all covered in full.*
- Routine physicals and physicals for school, sports and employment
- Women’s or men’s annual exams; well-baby and newborn exams
- Preventive immunizations
Preventive screenings—these are tests your doctor uses to make sure everything’s going well. The following screenings are covered in full.*
- Cancer Screenings—Cervical (PAP), prostate (PSA), mammograms and colonoscopies
- Infectious Disease Screenings—Chlamydia antibody and hepatitis antigen screenings
- Metabolic, Nutrition and Endocrine Screenings—Glucose testing (blood sugar) and anemia (iron deficiency) screenings
- Heart and Vascular Disease Screenings—Lipid panel/lipoprotein/high cholesterol screenings and high blood pressure testing
- Musculoskeletal Disorder Screening—Bone density screening
You’ll also have access to:
Online tools—Access to our secure website that includes tools to help you assess, manage and improve your health. Our secure website offers a health assessment, treatment
cost estimator, claims status, your plan benefits, symptom checker and several other useful tools.
Nationwide network coverage—The LifeWise network includes thousands of physicians, specialists and facilities in Oregon so you have a choice when it comes to your medical
care. You’re also covered when you travel nationwide by visiting a preferred provider with our partner network, PHCS/MultiPlan.
This is only a summary of major benefits. It is not a contract. |
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