WiseEssentials 50 Benefits from LifeWise Health Plans of Oregon Individual and Family Health Insurance

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Oregon Medical Insurance > LifeWise Health Plan of Oregon > WiseEssentials 50 Benefits

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

	WiseEssentials 50
	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
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
Office Visit including Urgent Care	Deductible, then 50%	Deductible, then 50%
Other Outpatient and Inpatient Professional Services	Deductible, then 50%
Alternative Care
Chiropractic	Not covered	Not covered
Acupuncture
Naturopathy	Deductible, then 50%	Deductible, then 50%
Diagnostic Services
Outpatient Diagnostic Imaging and Lab Services	Deductible, then 50%	Deductible, then 50%
Mammography	Deductible, then 50%
Pharmacy
Retail Pharmacy (30-day supply)	$20 Generics only	Not covered
Mail Service Pharmacy (90-day supply)	$50 Generics only
Emergency Care
Emergency Room Care	Deductible, then 50%
Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit)	Deductible, then 50%
Facility Care
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
Maternity Care	Deductible, then 50%	Deductible, then 50%
Vision Care
Routine Vision Exam	Not Covered
Vision Hardware
Other Services
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
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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