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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, 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 Prime |
Preferred Providers |
Non-Preferred Providers |
| Annual Deductible PCY1 |
Individual: $1,500 / $2,500 / $5,000 |
2x individual deductible |
| Coinsurance (what you pay) |
30% |
50% |
| Annual Coinsurance Maximum2 |
$6,000 |
$12,000 |
| Calendar Year Maximum |
$1,000,000 |
| Covered Services |
Preferred Providers |
Non-Preferred Providers |
| Office Visits, Urgent Care & Naturopathy |
DEDUCTIBLE WAIVED, you pay $30 on first 4 visits PCY; additional visits subject to deductible, then 30% |
Deductible, then 50% |
Preventive Care Exams
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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 WAIVED, $30 copay |
Deductible, then 50% |
Emergency Room Care
(copay waived if direct admit to an inpatient facility) |
$150 Copay, then subject to deductible, then 30% |
Ambulance Transportation
(Air: Unlimited; Ground $5,000 PCY limit) |
Preferred provider deductible, then 30% |
Outpatient Diagnostic Imaging & Lab Services
(X-Ray & Lab Services) |
Deductible, then 30% |
Deductible, then 50% |
| Inpatient/Outpatient Facility Care |
Deductible, then 30% |
Deductible, then 50% |
| Maternity Care |
Deductible, then 30% |
Deductible, then 50% |
Vision & Hearing Care—Routine Exam
(1 exam PCY) |
DEDUCTIBLE WAIVED, $30 Copay |
Deductible, then 50% |
Pharmacy (Retail: 30 day supply; Mail Order: 90 day supply)
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| Generics |
Retail: $20 Copay. Mail order: $60 Copay. Deductible waived |
Not covered |
| Preferred Brand & Non-Preferred Brand |
Select Drug List6 $500 Deductible. Retail 50%. Mail order: 50% |
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PCY = Per Calendar Year
- Family = 3x individual deductible.
- 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.
- Complications of pregnancy are covered at deductible, then coinsurance.
- The Select Drug List helps reduce prescription drug costs by excluding select medications that have over-the-counter (OTC)
alternatives available and brand name drugs that have generics available. Excluded drug classes because of ample OTC availability include cough and cold, antihistamines & heartburn/acid reflux
medications.
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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