Maddock and Associates
Insurance Specialists
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View Rates

(Available to Washington State Residents Only)
LifeWise of Health Plan of Washington
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
Lifetime maximum $2 million
 
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
Routine medical exam, sports physical & women's health/well baby exams
Preventative Screenings
PAP smear, PSA testing, colorectal colon cancer screening, cholesterol screening & bone density test

Covered in Full*
Immunizations Not Covered 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 DEDUCTIBLE WAIVED
then 25%
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 (6 visits PCY) DEDUCTIBLE WAIVED
then 25%


Deductible,
then 50%
Mental Health - Inpatient Facility Care (6 days PCY) Deductible,
then 25%
Transplants
(12-month waiting period; $350,000 lifetime benefit) Organ & Bone Marrow
Deductible,
then 25%
Not Covered

View Rates    * 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.”


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.
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