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Oregon Medical Insurance > LifeWise Health Plan of Oregon > WiseSavings Benefits

LifeWise Health Plans 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.”

 
WiseSavings (HSA Eligible)
 
Preferred Providers
Non-Preferred & extended providers
Annual Deductible PCY (choose one)
Individual: $3,000
Family: $6,000*
Coinsurance1 (what you pay)
20%
50%
Annual Coinsurance Maximum2
Individual: $2,000
Family: $4,000
Unlimited
Lifetime Maximum
$2,000,000
Covered Services
Preferred Providers
Non-Preferred & extended providers
Preventive Care
Preventive Care Exams
(routine medical exam, sports physical and women’s health exams/well baby)
DEDUCTIBLE WAIVED,
you pay 20%
Deductible, then 50%
Preventive Screenings
(includes Pap smear, PSA testing, home colon cancer screening, cholesterol screening and bone density test)
Covered in full3
Immunizations
Professional Care
Office Visit including Urgent Care
Deductible, then 20%
Deductible, then 50%
Other Outpatient and Inpatient Professional Services
Alternative Care
Chiropractic
12 visits PCY
(visits shared with Acupuncture)
Deductible, then 20%
Deductible, then 50%
Acupuncture
12 visits PCY
(visits shared with Chiropractic)
Naturopathy
Diagnostic Services
Outpatient Diagnostic Imaging and Lab Services
Deductible, then 20%
Deductible, then 50%
Mammography
Covered in full3
Pharmacy
Retail Pharmacy (30-day supply)
Deductible, then 50%;
Certain preventive generic drugs are reimbursed at 100%
Mail Service Pharmacy (90-day supply)
Deductible, then 45%;
Certain preventive generic drugs are reimbursed at 100%
Emergency Care
Emergency Room Care
Deductible, then 20%
Ambulance Transportation
Air (unlimited); Ground ($5,000 PCY limit)
Facility Care
Inpatient Facility Care
Deductible, then 20%
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 20%
Deductible, then 50%
Vision Care
Routine Vision Exam
Not Covered
Vision Hardware
Other Services
Supplies, Equipment and Prosthetics $5,000 PCY
Deductible, then 20%
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
1 All coinsurance amounts are the member’s percentage of maximum allowable amounts after deductible
2 Does not include deductible
3 Benefits provided at 100% of maximum allowable amounts; not subject to deductible or coinsurance
* 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.

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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