WiseValue Plus Rx
MEDICAL BENEFITS
for plans beginning April 1, 2012
NON-PREFERRED
PROVIDERS
PREFERRED PROVIDERS
Annual Deductible PCY (choose one)
(Family is 3x the individual deductible)
$1,000 / $2,500 / $5,000 / $7,500 / $10,000
Coinsurance1 (what you pay)
Annual Coinsurance Maximum2 (family = 2x individual)
Calendar Year Maximum
2x Individual Deductible
30%
50%
$5,000
$10,000
$2,000,000
COVERED SERVICES
PREFERRED PROVIDERS
NON-PREFERRED
PROVIDERS
Covered in Full3
Deductible, then 50%
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 “no deductible,”
“copay,” or covered in full.” PREVENTIVE CARE
Preventive Care Exams (routine medical exam, sports
physical and women’s health exams/well baby)
Preventive Screenings 4 (includes mammograms,
colonoscopies, PAP & PSA screenings)
Immunizations (includes HPV vaccine)
PROFESSIONAL CARE
Office Visit including Urgent Care and Naturopathy5
(with general physician, pediatrician, internist, nurse
practitioner, gynecologist, obstetrician, and naturopath)
DEDUCTIBLE WAIVED, you pay $20 on first 4 visits PCY;
additional visits subject to deductible, then 30%
Office Visit with Specialist (those not listed above)
DEDUCTIBLE WAIVED, you pay $75 on first 4 visits PCY;
additional visits subject to deductible, then 30%
Other Outpatient and Inpatient Professional Services
Supplemental Accident Benefit ($15,000 PCY limit;
Services must be received within 90 days of the injury)
Deductible, then 50%
Deductible, then 30%
DEDUCTIBLE WAIVED, you pay 30%
ALTERNATIVE CARE
Chiropractic & Acupuncture 12 visits each PCY
DEDUCTIBLE WAIVED, $30 copay
Deductible, then 50%
Basic Imaging/Lab Services: Deductible, then 30%;
Complex Imaging (PET, CT, MRA & MRI): Deductible,
then 50%
Deductible, then 50%
DIAGNOSTIC SERVICES
Outpatient Diagnostic Imaging and Lab Services
PHARMACY
Retail: 30-day supply
Mail Order: 90-day supply
Select Drug List6
Generics
Preferred Brand &
Non-Preferred Brand
DEDUCTIBLE WAIVED, you pay 50%
Not covered
$100 Deductible, then 50%
EMERGENCY CARE
Emergency Room Care
(copay waived if direct admit to an inpatient facility)
Ambulance Transportation
Air (unlimited); Ground ($5,000 PCY limit)
$100 Copay, then subject to preferred provider deductible, then 30%
Preferred provider deductible, then 30%
FACILITY CARE
Inpatient & Outpatient Facility Care
Skilled Nursing Facility 45 days PCY; includes room
and board, ancillaries and professional fees
Deductible, then 30%
Deductible, then 50%
Deductible, then 30%
Deductible, then 50%
PCY= Per Calendar Year
1
A member’s cost for covered services
after deductible
2
Does not include deductible
3
Benefits provided at 100% of
maximum allowable amounts.
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.
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.
5
Office visits, urgent care and
naturopathy are shared
6
Medicines with many over-thecounter (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.
MATERNITY
Maternity Care
(includes professional and facility care)
VISION CARE AND HEARING CARE
Routine Vision Exam 1 exam PCY
Hearing Hardware $5,000 in a consecutive 48-month
period; age limits apply
DEDUCTIBLE WAIVED, $30 copay
Preferred provider deductible, then 30%
OTHER SERVICES
Home Medical Equipment and Supplies
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
Alcohol Dependency Treatment
LWOR IP.WPS2 (11-2011)
Deductible, then 30%
Deductible, then 50%
This optional benefit is available at an additional cost.
This is only a summary of major
benefits. It is not a contract.
024420 (11-2011)
General exclusions and limitations
Some 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?
Waiting periods
Benefits are not provided for services, treatment, surgery,
drugs or supplies for any of the following:
Pre-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.
• Alcohol dependency treatment services (unless optional
alcohol endorsement is purchased)
• Allergy and testing injections (on WiseValue Plus and
WiseValue Plus Rx plan only)
• Biofeedback
• Chemical (drug addiction) dependency
• Conditions arising from acts of war or service in the military
• Cosmetic or reconstructive services, except as specifically
provided in the contract
• Dental services (except when covered under a
supplemental accident benefit)
• Experimental or investigative services
• Infertility
• Mental health
• Obesity/morbid obesity, including surgery, drugs, foods
and exercise programs.
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 Coverage
• Out-of-network drug coverage
If 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.
• Over-the-counter or non-prescription drugs
Creditable coverage includes:
• Services determined not to be medically necessary
• Any group healthcare coverage (including the Federal
Employees Health Benefits Plan and the Peace Corps)
• Orthognathic surgery (unless it meets medical criteria
and as required by ORS 743a.148)
• Services in excess of specified benefit maximums
• Services payable by other types of insurance coverage
• Services received when you are not covered by this plan
• Individual healthcare coverage (including student
healthcare coverage)
• Sexual dysfunction
• Medicare or Medicaid
• Sterilization reversal
• TRICARE
• Treatment for work-related conditions for which benefits
are provided by Workers’ Compensation or similar coverage
• Indian Health Service or tribal organization coverage
• Treatment of temporomandibular joint (TMJ) disorder
• A public health plan as defined in 42 U.S.C. 300gg,
as amended and in effect on July 1, 1997.
• Vision hardware (except for WiseOptimum plan)
Charges over the maximum
allowable amount
You may be responsible for charges that exceed the
maximum allowable amount for covered services provided
by non-preferred providers.
• State high-risk pool coverage