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LifeWise Health Plan of Oregon
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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.” PCY = Per Calendar Year
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WiseEssentials 50 |
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Preferred Providers |
Non-Preferred & extended providers |
Annual Deductible PCY (choose one)
(Family is 3x the individual deductible)* |
Individual: $1,500 / $3,000 |
4x individual deductible |
| Coinsurance1 (what you pay) |
50% |
50% |
Annual Coinsurance Maximum
(family = 2x individual)2 |
$9,000 |
Unlimited |
| Lifetime Maximum |
$2,000,000 |
| Covered Services |
Preferred Providers |
Non-Preferred & extended providers |
| Preventive Care
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Preventive Care Exams
1 exam PCY (routine medical exam, sports
physical and women’s health exams/well baby) |
DEDUCTIBLE WAIVED,
you pay 50% |
Deductible, then 50% |
Preventive Screenings
(includes Pap smear, PSA
testing, home colon cancer screening, cholesterol
screening and bone density test) |
Deductible, then 50% |
| Immunizations |
DEDUCTIBLE WAIVED,
you pay 50% |
| Professional Care
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| Office Visit including Urgent Care |
Deductible, then 50% |
Deductible, then 50% |
| Other Outpatient and Inpatient Professional Services |
Deductible, then 50% |
| Alternative Care
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| Chiropractic |
Not covered |
Not covered |
| Acupuncture |
| Naturopathy |
Deductible, then 50% |
Deductible, then 50% |
| Diagnostic Services
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| Outpatient Diagnostic Imaging and Lab Services |
Deductible, then 50% |
Deductible, then 50% |
| Mammography |
Deductible, then 50% |
| Pharmacy
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| Retail Pharmacy (30-day supply) |
$20 Generics only |
Not covered |
| Mail Service Pharmacy (90-day supply) |
$50 Generics only |
| Emergency Care
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| Emergency Room Care |
Deductible, then 50% |
| Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit) |
Deductible, then 50% |
| Facility Care
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| Inpatient Facility Care |
Deductible, then 50% |
Deductible, then 50% |
| Outpatient Facility Care |
| Skilled Nursing Facility 45 days PCY; includes room and
board, ancillaries and professional fees |
| Maternity
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| Maternity Care |
Deductible, then 50% |
Deductible, then 50% |
| Vision Care
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| Routine Vision Exam |
Not Covered |
| Vision Hardware |
| Other Services
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| Supplies, Equipment and Prosthetics $5,000 PCY |
Deductible, then 50% |
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 |
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PCY= Per Calendar Year
* Family = Individual plus one or more family members
1 All coinsurance amounts are the member’s percentage of maximum allowable amounts after deductible
2 Does not include deductible
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. |
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HealthNet
Oregon 