your guide - ehealthinsurance€¦ · you can also contact your producer or give us a call toll...

to Choosing a LifeWise Health Plan

Effective April 1, 2012

Your Guide

Part of your planLive smart!

You take responsibility for your health and you expect real value.LifeWise Health Plan of Oregon delivers. We’re here with service and support that works for you.

Here’s why you’ll like us...

Our plans focus on wellness,

prevention, choice and value.

We’re dedicated to service excellence. Our customer service and sales representatives are ready to help.

Our extensive provider network gives you easy access to thousands of healthcare providers and facilities in Oregon and nationwide.

We provide powerful, simple-to-use online tools to manage your coverage and protect your health.

How much coverage do

I need?

Do you need just a few office visits per year or more?

Do you need prescription coverage? Or are you willing to

pay for the few prescriptions you might need on your own?

Our easy to review charts on pages 4-7 will help you find the plan

that offers the coverage for services you use the most.

What cost options

work best for me?

Want to lower your out-of-pocket cost when you need care?

Look at our low deductible plans.

Looking to keep your monthly rate low and are willing to pay more

out-of-pocket when you need care? Consider a higher deductible plan.

What monthly rate works for you? See the enclosed Monthly

Rates brochure.

Close to making a

choice but need a little more information?

You’ll find more details about our plans at lifewiseor.com including a Supplemental Guide that shares information about:

Privacy Policies

Provider Organization

Key Utilization Management Procedures

Pharmaceutical Management Procedures

You can also contact your producer or give us a call toll free at 800-290-1278.

Important questions to consider

Important questions to considerOur plans are flexible enough to fit your needs and your budget.

Plus, they offer the best way to protect your health. Here are some important

things to think about as you look over the information on these pages:

lifewiseor.com • 800-290-1278 1

With LifeWise Health Plan of Oregon

Staying healthy

Preventive medical screenings are one of the best ways to

help you and your family stay healthy. These important

screenings help your doctors detect diseases early when they

are easiest to treat. All LifeWise plans offer comprehensive

preventive care coverage and you’ll pay the least out-of-

pocket when you visit an in-network provider. However,

you can see a non-preferred provider, but your cost will be

higher. The list below shows the most common preventive

care services we cover when you meet the frequency, age,

risk, and gender guidelines.

Covered ImmunizationsHepatitis A and B

Herpes

HPV

Flu

Chicken Pox

Polio

Preventive ExamsSports physicals

Routine physicals

Covered Preventive ScreeningsOsteoporosis: Bone density screening

Breast Cancer: Mammogram

Colorectal Cancer: Colonoscopy or sigmoidoscopy

Diabetes: Glucose test

High Blood Pressure, Hypertension,

Heart Disease, or Cholesterol: Lipid panel, lipoprotein, or

cholesterol screening

Prostate Cancer: PSA Blood Test

Anemia: Hemoglobin (iron) test

Cervical Cancer: PAP Smear

Infectious and Sexually Transmitted Diseases: Antibody

or antigen screening

Extensive coverage for preventive office visits and screenings*

You’ll also have access to:Online tools—Go to our secure website to help you

assess, manage and improve your health. Tools include a

health assessment, treatment cost estimator, claims status,

your plan benefits, symptom checker and more.

Nationwide network coverage—The LifeWise

network includes thousands of physicians, naturopaths,

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. Visit lifewiseor.com and

select "Find a Doctor" for more information.

24-Hour NurseLine—The Nurseline is staffed by

registered nurses who can answer questions about

symptoms and conditions. They'll also give you home

treatment suggestions and helpful advice about where to

get care.

Alternative care—Our plans cover acupuncture and

chiropractic alternative care services.

Health support and disease management—

LifeWise supports your health and helps you get the most

from your healthcare providers. We offer a variety of

information and services including personalized support

from an outreach nurse when you’re faced with complex

care needs.

24-hour coverage—On and off the job, you'll have

24-hour coverage for all enrolled family members. This

includes coverage for occupational conditions not covered

by workers’ compensation or other industrial insurance

provided by your employer.

Member discounts—Save money with special

discount offers on health products and services. Visit lifewiseor.com/discounts.

* A full list of preventive screenings, tests and other preventive services,

is available on lifewiseor.com.

Rotavirus

Shingles

Measles, Mumps and Rubella

Meningococcal and Pneumococcal

Tetanus, Diptheria, Pertussis

Women’s and men's health exams

Well baby exams

2

Review your plan options

What do you expect from your health plan?

WiseOptimum Plan Offers the widest range of covered benefits. This benefit-

rich plan gives you up-front coverage for your first four visits

to a primary care provider at the lowest copay. Plus, you get

coverage for unlimited visits to specialists at copay. This plan

also covers brand-name and generic drugs, vision, maternity

and has a supplemental accident benefit. A nice option if

you’re looking to cover all your bases.

WiseValue Plus PlanOffers great essential coverage. A good choice if you want

a low rate and more up-front coverage for routine care.

This plan covers your first three office visits at copay only,

and it covers generic prescriptions and has a supplemental

accident benefit.

WiseValue Plus Rx PlanProvides more coverage for the services you use the most.

A nice choice with a low rate and up-front coverage for your

first four visits to a primary care provider at copay. Plus, it

covers four visits to specialists at copay. This plan also has a

supplemental accident benefit and covers brand-name and

generic drugs.

WiseHSA PlanOffers great essential coverage and the chance to save

money pre-tax for future healthcare expenses. This plan

covers office visits, prescriptions, and most other common

services at deductible then coinsurance.


Choose the best plan for you

1 A member’s cost for covered services after deductible2 Does not include deductible.3 Benefits provided at 100% of maximum allowable amount. This is not subject to deductible or coinsurance.4 A full list of preventive screenings, tests and other preventive services, is available on lifewiseor. com.

These preventive services are covered in full if you use preferred providers and meet the frequency, age, risk and gender guidelines outlined in the list.

PCY = Per Calendar Year Calendar year maximum = $2 million

WiseOptimum Plan WiseValue Plus WiseValue Plus RxPreferred Providers Non-Preferred Providers Preferred Providers Non-Preferred Providers Preferred Providers Non-Preferred Providers

Annual Deductible PCY (choose one) (Family is 3x the individual deductible) $1,000 / $2,500 / $5,000 2x individual deductible $2,500 / $5,000 2x Individual Deductible $1,000 / $2,500 / $5,000 / $7,500 / $10,000 2x Individual Deductible

Coinsurance1 (what you pay) 20% 50% 35% 50% 30% 50%

Annual Coinsurance Maximum (family = 2x individual)2 $3,000 $6,000 $5,000 $10,000 $5,000 $10,000

Preventive Care Exams (routine medical exam, sports physical and women’s health exams/well baby)

Covered in full3 Deductible, then 50% Covered in Full3 Deductible, then 50% Covered in Full3 Deductible, then 50%Preventive Screenings4 (includes mammograms, colonoscopies, PAP & PSA screenings)

Immunizations (includes HPV vaccine)

Office Visit including Urgent Care and Naturopathy (with general physician, pediatrician, internist, nurse practitioner, gynecologist, obstetrician, and naturopath)

DEDUCTIBLE WAIVED, you pay $10 on first 4 visits PCY; additional visits subject to deductible, then 20%

Deductible, then 50%




Deductible, then 50%Office Visit with Specialist (those not listed above) DEDUCTIBLE WAIVED, you pay $75 (unlimited visits) DEDUCTIBLE WAIVED, you pay $75 on first 4 visits PCY;

additional visits subject to deductible, then 30%

Other Outpatient and Inpatient Professional Services Deductible, then 20% Deductible, then 35% Deductible, then 30%

Supplemental Accident Benefit (Services must be received within 90 days of the injury) DEDUCTIBLE WAIVED, you pay 20% (unlimited) DEDUCTIBLE WAIVED, you pay 35% ($15,000 PCY limit) DEDUCTIBLE WAIVED, you pay 30% ($15,000 PCY limit)

Chiropractic & Acupuncture 12 visits each PCY DEDUCTIBLE WAIVED, $30 Copay Deductible, then 50% DEDUCTIBLE WAIVED, $35 copay Deductible, then 50% DEDUCTIBLE WAIVED, $30 copay Deductible, then 50%

Outpatient Diagnostic Imaging and Lab Services Deductible, then 20% Deductible, then 50%Basic Imaging/Lab Services: Deductible, then 35%;

Complex Imaging (PET, CT, MRA, & MRI): Deductible, then 50%

Deductible, then 50%Basic Imaging/Lab Services: Deductible, then 30%;



Pharmacy

Retail: 30-day supply Mail Order: 90-day supplySelect Drug List5 (applies to WiseOptimum and WiseValue Plus Rx)

Generics/BrandRetail: $15/50%

Mail Order: $45/50%Preventive generic drugs: Covered in full

Not coveredGenerics: DEDUCTIBLE WAIVED, you pay 50%

Brand: Not coveredNot covered

Generics: DEDUCTIBLE WAIVED, you pay 50%Brand: $100 Deductible, then 50%

Not covered

Emergency Room Care (copay waived if direct admit to an inpatient facility) $100 Copay, then subject to preferred provider deductible, then 20% $100 Copay, then subject to preferred provider deductible, then 35% $100 Copay, then subject to preferred provider deductible,then 30%

Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit) Preferred provider deductible, then 20% Preferred provider deductible, then 35% Preferred provider deductible, then 30%

Inpatient and Outpatient Facility Care

Deductible, then 20% Deductible, then 50% Deductible, then 35% Deductible, then 50% Deductible, then 30% Deductible, then 50%Skilled Nursing Facility 45 days PCY; includes room and board, ancillaries and professional fees

Maternity Care (includes professional and facility care) Deductible, then 20% Deductible, then 50% Deductible, then 35% Deductible, then 50% Deductible, then 30% Deductible, then 50%

Vision Care Routine Vision Exam: DEDUCTIBLE WAIVED, $30 Copay. (1 exam PCY) $50 for frames, lenses, and contact lenses per 2 calendar years Routine Vision Exam: DEDUCTIBLE WAIVED, $35 copay (1 exam PCY) Routine Vision Exam: DEDUCTIBLE WAIVED, $30 copay (1 exam PCY)

Hearing Hardware $5,000 in a consecutive 48-month period; age limits apply Preferred provider deductible, then 20% Preferred provider deductible, then 35% Preferred provider deductible, then 30%

Home Medical Equipment and Supplies

Deductible, then 20% Deductible, then 50% Deductible, then 35% Deductible, then 50% Deductible, then 30% Deductible, then 50%

Home Health Care 130 visits PCY

Hospice Care Inpatient: 10 days, Outpatient 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) 24-month waiting period; Donor and travel limits apply

4

Choose the best plan for you

See pages 6-7 for Health Savings 5 Medicines with many over-the-counter (OTC) alternatives and brand name drugs with generic options are not on the Select Drug List. These medicines are not covered. Examples include cough and cold, antihistamines & heartburn/acid reflux medicines.

This is only a summary of the major benefits provided by our plans. This is not a contract.

To review a complete list of covered plan benefits, visit lifewiseor.com/healthplans.

Deductible, coinsurance and copay represent what you pay. All covered services are based on maximum allowable amounts. Benefits apply after you meet your calendar year deductible, unless you see “deductible waived,” “copay,” or “covered in full.”


WiseOptimum Plan WiseValue Plus WiseValue Plus RxPreferred Providers Non-Preferred Providers Preferred Providers Non-Preferred Providers Preferred Providers Non-Preferred Providers

Annual Deductible PCY (choose one) (Family is 3x the individual deductible) $1,000 / $2,500 / $5,000 2x individual deductible $2,500 / $5,000 2x Individual Deductible $1,000 / $2,500 / $5,000 / $7,500 / $10,000 2x Individual Deductible

Coinsurance1 (what you pay) 20% 50% 35% 50% 30% 50%

Annual Coinsurance Maximum (family = 2x individual)2 $3,000 $6,000 $5,000 $10,000 $5,000 $10,000


Covered in full3 Deductible, then 50% Covered in Full3 Deductible, then 50% Covered in Full3 Deductible, then 50%Preventive Screenings4 (includes mammograms, colonoscopies, PAP & PSA screenings)


Office Visit including Urgent Care and Naturopathy (with general physician, pediatrician, internist, nurse practitioner, gynecologist, obstetrician, and naturopath)






Deductible, then 50%Office Visit with Specialist (those not listed above) DEDUCTIBLE WAIVED, you pay $75 (unlimited visits) DEDUCTIBLE WAIVED, you pay $75 on first 4 visits PCY;

additional visits subject to deductible, then 30%

Other Outpatient and Inpatient Professional Services Deductible, then 20% Deductible, then 35% Deductible, then 30%

Supplemental Accident Benefit (Services must be received within 90 days of the injury) DEDUCTIBLE WAIVED, you pay 20% (unlimited) DEDUCTIBLE WAIVED, you pay 35% ($15,000 PCY limit) DEDUCTIBLE WAIVED, you pay 30% ($15,000 PCY limit)

Chiropractic & Acupuncture 12 visits each PCY DEDUCTIBLE WAIVED, $30 Copay Deductible, then 50% DEDUCTIBLE WAIVED, $35 copay Deductible, then 50% DEDUCTIBLE WAIVED, $30 copay Deductible, then 50%

Outpatient Diagnostic Imaging and Lab Services Deductible, then 20% Deductible, then 50%Basic Imaging/Lab Services: Deductible, then 35%;


Deductible, then 50%Basic Imaging/Lab Services: Deductible, then 30%;



Pharmacy

Retail: 30-day supply Mail Order: 90-day supplySelect Drug List5 (applies to WiseOptimum and WiseValue Plus Rx)

Generics/BrandRetail: $15/50%

Mail Order: $45/50%Preventive generic drugs: Covered in full

Not coveredGenerics: DEDUCTIBLE WAIVED, you pay 50%

Brand: Not coveredNot covered

Generics: DEDUCTIBLE WAIVED, you pay 50%Brand: $100 Deductible, then 50%

Not covered

Emergency Room Care (copay waived if direct admit to an inpatient facility) $100 Copay, then subject to preferred provider deductible, then 20% $100 Copay, then subject to preferred provider deductible, then 35% $100 Copay, then subject to preferred provider deductible,then 30%

Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit) Preferred provider deductible, then 20% Preferred provider deductible, then 35% Preferred provider deductible, then 30%

Inpatient and Outpatient Facility Care

Deductible, then 20% Deductible, then 50% Deductible, then 35% Deductible, then 50% Deductible, then 30% Deductible, then 50%Skilled Nursing Facility 45 days PCY; includes room and board, ancillaries and professional fees

Maternity Care (includes professional and facility care) Deductible, then 20% Deductible, then 50% Deductible, then 35% Deductible, then 50% Deductible, then 30% Deductible, then 50%

Vision Care Routine Vision Exam: DEDUCTIBLE WAIVED, $30 Copay. (1 exam PCY) $50 for frames, lenses, and contact lenses per 2 calendar years Routine Vision Exam: DEDUCTIBLE WAIVED, $35 copay (1 exam PCY) Routine Vision Exam: DEDUCTIBLE WAIVED, $30 copay (1 exam PCY)

Hearing Hardware $5,000 in a consecutive 48-month period; age limits apply Preferred provider deductible, then 20% Preferred provider deductible, then 35% Preferred provider deductible, then 30%


Deductible, then 20% Deductible, then 50% Deductible, then 35% Deductible, then 50% Deductible, then 30% Deductible, then 50%


Hospice Care Inpatient: 10 days, Outpatient Respite: 240 hours – per 6 months lifetime maximum



Account (HSA)-qualified plans


Get the tax advantage with a WiseHSA health plan

Find a complete list of covered plan benefits at lifewiseor.com/healthplans.

What is a Health Savings Account (HSA)?A HSA is an individually-owned bank account that you set up, manage and fund. It lets you set aside funds to pay for your healthcare on a tax-advantaged basis and works in conjunction with HSA-qualified health plans. Before you can open an HSA bank account, you must first be covered by a qualified high-deductible health plan.

What are the benefits of a HSA?With your HSA bank account, you put money in and take it out, just like you would with a regular savings account. The difference is the money may be tax-free if you use it to cover qualified medical expenses. Your HSA can provide a triple tax advantage because:

•Contributionsaremadeonatax-advantagedbasis

•Moneycanbewithdrawntax-freewhenyouuseittopay for qualified medical expenses.

•Unusedfundsrolloverfromyeartoyearandgrowtax-deferred.

A HSA offers interest and investment options. Once you meet the minimum balance you can invest in mutual fund families. And you can save up your HSA funds for certain future healthcare expenses, including those in retirement.

We offer integrated banking through UMB Bank n.a., a member of the FDIC. Founded in 1913 and an industry leader in financial healthcare accounts since 1997, UMB Bank is one of the largest independent banks in America. Your account offers:

•nomonthlyservicefees

•ahealthcarepayment(debit)card

•24-7onlineaccess,givingyoutheaddedconveniencetotrack and manage your qualified healthcare expenses.

You can also use other qualified banks, such as HSA Bank™.

The WiseHSA health plan

More than a medical plan— it’s a financial plan, tooThe WiseHSA health plan might be the right fit if you want to:

•Saveandinvestforfuturehealthcareexpenses

•Decreasetheamountoftaxesyoupay.

How to enroll

1 Apply for the WiseHSA health plan— Enroll in the WiseHSA plan described on the next page.

2 Open a HSA bank account—LifeWise has established a relationship with UMB Bank, n.a. to give

you an integrated banking experience. To open your account, visit lifewiseor.com to download the short authorization form. You can also call us at 800-290-1278 or contact your producer.

3 Start contributing to your HSA account—Watch your money grow year-to-year. You can manage

your HSA online by visiting lifewiseor.com and logging in.

This material is not intended to provide tax or legal advice. Individuals and families

should consult with their own legal and tax advisors before taking action. For more

detailed information on HSAs, refer to IRS Publication 969, “Health Savings Accounts

and Other Tax-Favored Health Plans,” by visiting the IRS Web site.

6

Get the tax advantage with a WiseHSA health plan

Find a complete list of covered plan benefits at lifewiseor.com/healthplans.

Quality healthcare coverage and the opportunity to save money on a pre-tax basis for future qualified medical expenses. Make your money work for you with an HSA-qualified heath plan.

Deductible, coinsurance and copay represent what you pay. All covered services are based on maximum allowable amounts.

Benefits apply after you meet your calendar year deductible, unless you see “deductible waived,” “copay,” or “covered in full.”

1 Family equals individual plus one or more family members. Services for all family members covered under the same HSA-qualified plan are applied to the same deductible. The family deductible must be met before services are covered for any enrolled family members.

2 A member’s cost for covered services after deductible3 Does not include deductible4 Benefits provided at 100% of maximum allowable amounts. This is not subject

to deductible or coinsurance


HSA-Qualified Health PlansPreferred Providers Non-Preferred Providers

Annual Deductible PCY (choose one) preferred and non-preferred share a deductible

$3,000 Individual $6,000 Family1




Coinsurance2 (what you pay) 50% 0% 50%

Annual Coinsurance Maximum3 $2,000 Individual $4,000 Family $0 $4,000 Individual

$8,000 Family$11,900 Individual

$23,800 Family


Covered in full 4 Covered in full4 Deductible, then 50%Preventive Screenings (includes mammograms, colonoscopies, PAP & PSA screenings)5


Office Visit including Urgent Care, Specialists and Naturopathy Deductible,

then 50%Deductible, then

covered in full Deductible, then 50%Other Outpatient and Inpatient Professional Services

Chiropractic & Acupuncture 12 visits each PCY Deductible, then 50%

Deductible, then covered in full Deductible, then 50%

Outpatient Diagnostic Imaging and Lab Services Deductible, then 50% Deductible, then covered in full Deductible, then 50%

Pharmacy

Retail: 30-day supply Mail Order: 90-day supply

Preventive generic drugs: Covered in full

Generics & Brand: Deductible, then 50%

Select Drug List6

Generics: Deductible, then

covered in full

Brand: Not covered

Not covered

Emergency Room Care Deductible, then 50%

Deductible, then covered in full

Preferred provider deductible, then preferred provider coinsuranceAmbulance Transportation Air (unlimited);

Ground ($5,000 PCY limit)

Inpatient and Outpatient Facility CareDeductible, then 50%

Deductible, then covered in full Deductible, then 50%Skilled Nursing Facility 45 days PCY; includes

room and board, ancillaries and professional fees

Maternity Care (includes professional and facility care) Deductible, then 50% Deductible, then covered in full Deductible, then 50%

Routine Vision Exam 1 exam PCY Deductible, then 50% Deductible, then covered in full Preferred provider deductible, then preferred provider coinsurance

Hearing Hardware $5,000 in a consecutive 48-month period; age limits apply Preferred provider deductible, then preferred provider coinsurance


Deductible, then 50% Deductible, then covered in full Deductible, then 50%


Hospice Care Inpatient:10 days, Outpatient Respite: 240 hours – per 6 months lifetime maximum



5 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.

6 Medicines with many over-the-counter (OTC) alternatives and brand name drugs with generic options are not on the Select Drug List. These medicines are not covered. Examples include cough and cold, antihistamines & heartburn/acid reflux medicines.


Balance billing—Additional charges you may have to pay if you use a non-preferred provider.

Benefit—The portion of services your health plan pays for.

Coinsurance—Your share of the cost for a service once your deductible is met. If your plan’s coinsurance share is 20%, you pay 20% of the maximum allowable amount and your plan pays the other 80% of the maximum allowable amount.

Coinsurance maximum—A preset limit. After you meet this limit, your plan will pay 100% of the maximum allowable amount.

Copay—A flat amount you pay for a specific service, like an office visit, at the time of service. Copays don’t apply towards a deductible or coinsurance maximum.

1 Apply online at lifewiseor.com—Get a quote,

fill out your application and submit it electronically on

our secure site. Prompts will guide you through the easy

step-by-step process.

2 Apply by mail—Fill out, sign and date your

LifeWise enrollment application, then send it to us in

the pre-addressed envelope provided.

3 Talk to a producer—Find out more about which

LifeWise health plan is right for you. Your producer

can also help you submit an online application.

How to become a LifeWise member

Covered in full—Services your plan pays for in full. Benefits provided at 100% of the maximum allowable amount; not subject to deductible or coinsurance.

Deductible—The amount of money you pay every year before your plan will pay for certain services.

Maximum allowable amount—The most LifeWise will pay for a covered service.

Network—A group of doctors, hospitals and other healthcare providers that have been contracted to provide services and supplies at negotiated amounts called “maximum allowable amounts.”

Preferred provider—A physician, healthcare specialist, or medical facility that belongs to the LifeWise network.

Helpful definitions

As a LifeWise member

You get access to our secure Web site where

you can:

Order new ID cards, check claims status, see

your benefits and estimate treatment costs

Choose your monthly payment option including

automatic funds transfer, credit card or debit card.

Visit lifewiseor.com for more details.

Enroll today!

Are you eligible?You must be a resident of the state of Oregon and not eligible for Medicare to apply. To review additional eligibility requirements, please refer to the application.

8

General exclusions and limitationsSome services may require prior authorization. Certain services must be prior authorized in writing before you receive

care. If you do not request prior authorization when required, you will be subject to a penalty of 50% of the maximum

allowable amount, up to a maximum of $500 per occurrence. Additionally, benefit plans typically have exclusions and

limitations—what the plans do not cover. The following are general exclusions and limitations for the LifeWise benefit

plans. For a complete list of exclusions and limitations, please visit lifewiseor.com.

What is not covered?Benefits are not provided for services, treatment, surgery, drugs or supplies for any of the following:

•Alcoholdependencytreatmentservices(unlessoptionalalcohol endorsement is purchased)

• Allergyandtestinginjections(onWiseValuePlusandWiseValue Plus Rx plan only)

• Biofeedback• Chemical(drugaddiction)dependency• Conditionsarisingfromactsofwarorserviceinthemilitary• Cosmeticorreconstructiveservices,exceptasspecifically

provided in the contract• Dentalservices(exceptwhencoveredundera

supplemental accident benefit)• Experimentalorinvestigativeservices• Infertility•Mentalhealth• Obesity/morbidobesity,includingsurgery,drugs,foods

and exercise programs. • Orthognathicsurgery(unlessitmeetsmedicalcriteria

and as required by ORS 743a.148)• Out-of-networkdrugcoverage• Over-the-counterornon-prescriptiondrugs• Servicesdeterminednottobemedicallynecessary• Servicesinexcessofspecifiedbenefitmaximums• Servicespayablebyothertypesofinsurancecoverage• Servicesreceivedwhenyouarenotcoveredbythisplan• Sexualdysfunction• Sterilizationreversal• Treatmentforwork-relatedconditionsforwhichbenefits

are provided by Workers’ Compensation or similar coverage• Treatmentoftemporomandibularjoint(TMJ)disorder• Visionhardware(exceptforWiseOptimumplan)

Charges over the maximum allowable amountYou may be responsible for charges that exceed the maximum allowable amount for covered services provided by non-preferred providers.

Waiting periodsPre-existing Condition—LifeWise individual health benefit plans have a six-month waiting period for conditions you already have. That means we don’t cover any conditions you already have in the first six months after your coverage begins. A pre-existing condition is any medical condition that you received advice, a diagnosis, care or treatment was recommended or received within six months prior to enrolling in the plan and the date your coverage started. These waiting periods are waived for children under age 19.

Organ Transplant Benefit Exclusion Period— A benefit exclusion period is a time when the plan does not cover certain treatment or services. LifeWise individual health benefit plans have a 24-month benefit exclusion period for organ transplant services. This period begins on the date your coverage starts.

Creditable CoverageIf you had healthcare coverage that ended less than 63 days before you enrolled in a LifeWise plan, it is “creditable coverage.” LifeWise will reduce your waiting periods by the amount of creditable coverage you have.

Creditable coverage includes:

• Anygrouphealthcarecoverage(includingtheFederalEmployees Health Benefits Plan and the Peace Corps)

• Individualhealthcarecoverage(includingstudenthealthcare coverage)

•MedicareorMedicaid

• TRICARE

• IndianHealthServiceortribalorganizationcoverage

• Statehigh-riskpoolcoverage

• Apublichealthplanasdefinedin42U.S.C.300gg, asamendedandineffectonJuly1,1997.

Enroll today!


LWOR IP.MBR (11-2011)LifeWise Health Plan of Oregon

Please note that this brochure is not a contract, nor is it a complete explanation of plan benefits or exclusions and limitations for LifeWise Health Plan of Oregon plans. The complete terms of coverage are determined by the contract.

Start enjoying the LifeWise advantage!

Talk to your producer about the plan that’s right for you. Or call us directly at:

800-290-1278 800-842-5357 (TDD for the hearing-impaired)

lifewiseor.com

008701 (11-2011)

your guide - ehealthinsurance€¦ · you can also contact your producer or give us a call toll...

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