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(Available to Washington State Residents Only) |
WiseEssentials Copay Summary of Benefits
All services subject to plan's deductible, unless otherwise noted.
| PCY = Per Calendar Year |
Coinsurance and copay represent WHAT YOU PAY. |
| MEDICAL PLAN |
Preferred Provider |
Non-Preferred Provider |
Annual Deductible
PCY (choose
one; no family deductible)
|
$5,000/$7,500 |
$10,000/$15,000 |
| Coinsurance (what you
pay) |
25% |
50% |
Annual Coinsurance Maximum
|
$5,000 |
Unlimited |
COVERED SERVICES
Annual Maximum: $2,000,000
Lifetime Maximum: Unlimited
|
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Office Visits including Urgent Care & Naturopathy |
DEDUCTIBLE WAIVED
on first 3 visits PCY you pay $25 copay only; additional visits subject to deductible, then 25% |
Deductible,
then 50% |
|
Preventive Care Exams |
Covered in Full* |
Preventative Screenings
A full list of preventive screenings, tests and services is available on lifewisewa.com |
Covered in Full* |
|
Immunizations |
Covered in Full* |
Not Covered |
| Pharmacy - Retail |
Not Covered
(Pharmacy discount
program available)** |
Not Covered
(Pharmacy discount
program available)** |
| Pharmacy - Mail Service |
| Outpatient Diagnostic Imaging & Lab Services |
Deductible, then 25% |
Deductible,
then 50% |
| Mammography |
Covered in Full* |
Emergency Room Care
Copay waived if direct admit to an inpatient facility |
$100 copay, then subject to deductible, then 25% |
$100 copay, then subject to deductible, then 25%*** |
Ambulance Transportation
Air:
unlimited;
Ground: $5,000 PCY limit |
Deductible,
then 25% |
Deductible,
then 25%*** |
Outpatient & Inpatient
Facility Care |
Deductible,
then 25% |
Deductible,
then 50% |
Rehabilitation (Outpatient: 20 visits PCY;
Inpatient: 8 days PCY) Physical, Occupational, Massage & Speech Therapy; Cardiac &
Pulmonary Rehabilitation |
| Durable Medical Equipment & Prosthetics |
Not Covered |
Not Covered |
Spinal & Other Manipulations
(12 visits PCY) |
DEDUCTIBLE WAIVED
$25 Copay |
Deductible,
then 50% |
Acupuncture
(12 visits PCY) |
Home Health Care
(130 visits
PCY) |
Deductible,
then 25% |
Deductible,
then 50% |
Skilled Nursing Facility (45 days
PCY) Includes room and board, ancillaries
& professional fees |
Hospice Care
(Inpatient: 10 days PCY; Respite: 240 hours PCY) |
| Maternity Care |
Not Covered |
Not Covered |
| Vision Care - Routine Exam |
Not Covered |
Not Covered |
| Vision Care - Hardware |
| Mental Health - Outpatient Office Visit |
DEDUCTIBLE WAIVED
on first 3 visits PCY you pay $25 copay only; additional visits subject to deductible, then 25% |
Deductible,
then 50% |
| Mental Health - Inpatient Facility Care |
Deductible,
then 25% |
Transplants
(12-month waiting period; $350,000 lifetime benefit) Organ & Bone Marrow |
Deductible,
then 25% |
Not Covered |
* Benefits provided at 100% of allowable charges; not subject to deductible
or coinsurance.
** In order to validate current eligibility for this discount, the pharmacy will transmit
your information to LifeWise Health Plan of Washington, including the details of
the prescription to
be filled. The information may also be used for other proper
purposes.
*** Unlike services received at other non-preferred providers, this service is subject
to the preferred provider deductible and coinsurance.
Deductible, coinsurance and copay represent what you pay. Benefits apply after calendar year deductible is met, unless otherwise noted as “Deductible Waived,” “Copay” or “Covered in Full.”
LifeWise Dental CoPay Plan Summary of Benefits - Optional Ad-On Benefit
(Optional benefits that are not elected are excluded from coverage)
Here are a few examples of common services this plan covers when you choose a preferred provider:
| PCY = Per Calendar Year |
Coinsurance and copay represent WHAT YOU PAY. |
| COMMONLY USED COVERED SERVICES |
PREFERRED PROVIDER |
NON-PREFERRED PROVIDER |
| Annual Deductible PCY |
Individual: $50 / $75
Family: $150 / $225 |
Benefit Maximum
per person, PCY |
$1,000 |
DIAGNOSTIC & PREVENTIVE
(no deductible applies) |
$50 or $75 deductible plan |
$50 deductible plan |
$75 deductible plan |
| Oral Exams limited to 2 PCY |
$0 |
20% |
30% |
| Bitewing X-rays |
$0 |
20% |
30% |
| Cleanings Limited to 2 PCY |
$20 |
20% |
30% |
| Flouride Treatments limited to 2 applications PCY for members under the age of 20 |
$0 |
20% |
30% |
| Sealants limited to permanent teeth; for members under age 19 |
$0 |
20% |
30% |
| BASIC (deductible applies first) |
$50 or $75 deductible plan |
$50 deductible plan |
$75 deductible plan |
| Emergency Palliative Treatment |
$5 |
40% |
50% |
| Filings one surface, amalgam; primary or permanent; limited to once per tooth surface every 24 consecutive months |
$30 |
40% |
50% |
| Periodontal Maintenance limited to 4 visits per calendar year |
$40 |
40% |
50% |
| Recementing of Crowns |
$20 |
40% |
50% |
| Crown Repair |
$25 |
40% |
50% |
| Simple Extractions erupted tooth or exposed root |
$30 |
40% |
50% |
| Space Maintainers fixed, unilateral; for members under age 20 |
$65 |
40% |
50% |
| MAJOR (12 month waiting period; deductible applies first) |
$50 or $75 deductible plan |
$50 deductible plan |
$75 deductible plan |
| Crowns, Onlays, Dentures, Partials and Bridges |
Copays vary based on the tooth location and type of material used.
Visit lifewisewa.com/dental for a complete list of covered services and copays for more information. |
60% |
70% |
| Endodontic (Root Canal) Treatment limited to 2 per arch when performed in conjunction with overdentures |
anterior tooth: $385
molar tooth: $515
bicuspid tooth: $435 |
60% |
70% |
| General Anesthesia for first 30 minutes; limited to covered dental procedures at a dental-care provider’s office when dentally necessary |
$165 |
60% |
70% |
| Oral Surgery for surgical removal of residual tooth roots |
$115 |
60% |
70% |
| Periodontal Scaling one to three teeth; limited to 2 every 12 consecutive months |
$60 |
60% |
70% |
| Periodontal Surgery osseous surgery; one to three contiguous teeth; limited to 2 every 12 consecutive months |
$350 |
60% |
70% |
Click here to view the full list of Covered Services and CoPay Schedule.
* If you visit a non-preferred provider, you'll pay the applicable non-preferred coinsurance based on the type of service provided.
You'll also be responsible for amounts charged in excess of the allowable charge. Visit lifewisewa.com/dental for details on non-preferred provider coverage.
This is a only a summary of the major benefits provided by this plan. This is not a contract. For full coverage provisions, including a description of waiting periods, limitations, and exclusions, refer to the plan contract.
E-mail us for more information and a free quote or CALL TOLL FREE
1-800-875-4490 (in the U.S.)
or 1-253-854-0199 (outside the U.S.)
Fax: 1-253-896-9411
Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424
Serving all of Washington at 800-875-4490, Seattle at 206-682-1628,
Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291.
Copyright© 1998-2011, Maddock & Associates | Privacy Statement
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