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Oregon Medical Insurance > LifeWise Health Plan of Oregon > WiseChoices 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.” PCY = Per Calendar Year

 
WiseChoices
 
Preferred Providers
Non-Preferred & extended providers
Annual Deductible PCY (choose one)
(Family is 3x the individual deductible)*
Individual: $500 / $1,000 / $2,500 / $5,000
2x individual deductible
Coinsurance1 (what you pay)
20%
50%
Annual Coinsurance Maximum
(family = 2x individual)
$7,500
Unlimited
Out-of-Pocket Maximum
Annual deductible + coinsurance maximum
Office Visit Cost Share
$20 Copay per visit
Deductible applies first, then you pay 50%
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)2
$20 Copay per visit
Deductible applies first, then you pay 50%
Preventive Screenings
(includes Pap smear, PSA testing, home colon cancer screening, cholesterol screening and bone density test)
Covered in full2
Immunizations
Professional Care
Office Visit including Urgent Care
$20 Copay per visit
Deductible applies first, then you pay 50%
Other Outpatient and Inpatient Professional Services
Deductible applies first, then you pay 20%
Alternative Care
Spinal and Other Manipulations 12 visits PCY
(visits shared with Acupuncture)
$25 Copay per visit
Deductible applies first, then you pay 50%
Acupuncture 12 visits PCY
(visits shared with Spinal and Other Manipulations)
Naturopathy
$20 Copay per visit
Diagnostic Services
Outpatient Diagnostic Imaging and Lab Services
Deductible applies first, then you pay 20%
Deductible applies first, then you pay 50%
Mammography
Covered in full2
Pharmacy
Retail Pharmacy (30-day supply)
$20 Generics; 50% Brand
Preferred cost share + 40%
Mail Service Pharmacy (90-day supply)
$50 Generics; 45% Brand
Emergency Care
Emergency Room Care (copay waived if direct admit to an inpatient facility)
$100 Copay per visit;
Deductible applies first, then you pay 20%
Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit)
Deductible applies first, then you pay 20%
Facility Care
Inpatient Facility Care
Deductible applies first, then you pay 20%
Deductible applies first, then you pay 50%
Outpatient Facility Care
Skilled Nursing Facility 45 days PCY; includes room and board, ancillaries and professional fees
Maternity
Maternity Care
Deductible applies first, then you pay 20%
Deductible applies first, then you pay 50%
Vision Care
Routine Vision Exam
Covered in full2
Vision Hardware
$200 for frames, lenses and contact lenses
Other Services
Supplies, Equipment and Prosthetics $5,000 PCY
Deductible applies first, then you pay 20%
Deductible applies first, then you pay 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
Accident Benefit $1,000 PCY
First $1,000 is covered in full2 PCY; then paid as any other illness subject to deductible/coinsurance
Alcohol Dependency Treatment
This optional benefit is available at an additional cost. It is limited to $4,500 in any 24 consecutive months

* Family = Individual plus one or more family members
1 All coinsurance amounts are the member’s percentage of maximum allowable amounts after deductible
2 Benefits provided at 100% of maximum allowable amounts; not subject to deductible or coinsurance.

This is only a summary of major benefits. It is not a contract.

 
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