Regence BlueShield   LifeWise of WA Plans   Comprehensive Plans     WiseChoices Prime   Catastrophic Plans     WiseEssentials Rx     WiseEssentials CoPay     WiseSimplicity   HSA Plan     WiseSavings   Plan Rates   Apply Now!   Prescription Drugs   Provider Directory   Waiting Period     & Exclusions   FAQ's   Group Health   HSA Plans   Individual Dental   Group Medical   Group Dental   Grp Life & Disability   About the Plan   Premiums   Application   (Available to Washington State Residents Only) WiseChoices Prime - Summary of Benefits All services subject to plan's deductible, unless otherwise noted. Coinsurance is 30%. PCY = Per Calendar Year Coinsurance and copay represent WHAT YOU PAY. MEDICAL PLAN Preferred Provider Non-Preferred Provider Annual Deductible PCY (choose one) Individual: $1,500 Family: $4,500 Individual: $3,000 Family: $9,000 Coinsurance (what you pay) 30% 50% Annual Coinsurance Maximum $6,500 Individual or Family = 3x Individual Unlimited COVERED SERVICES Annual Maximum: $2,000,000 Lifetime Maximum: Unlimited   Office Visits including Urgent Care & Naturopathy DEDUCTIBLE WAIVED $30 Copay 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 Not Covered Pharmacy - Retail (30-day supply) Brand: $3,000 PCY limit; Generic: Unlimited $10/30%/50%/30% Not Covered Pharmacy - Mail Order (90-day supply) Brand: $3,000 PCY limit; Generic: Unlimited $25/25%/45%/30% Outpatient Diagnostic Imaging & Lab Services Deductible, then 30% 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 30% $100 copay, then subject to deductible, then 30%** Ambulance Transportation Air: unlimited; Ground: $5,000 PCY limit Deductible, then 30% Deductible, then 30%** Outpatient & Inpatient Facility Care Deductible, then 50% Rehabilitation (Outpatient: 20 visits PCY; Inpatient: 8 days PCY) Physical, Occupational, Massage & Speech Therapy; Cardiac & Pulmonary Rehabilitation Durable Medical Equipment & Prosthetics ($5,000 PCY) 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 30% 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 Deductible, then 30% Deductible, then 50% Vision Care - Routine Exam (One exam per two calendar years) Covered in Full* Covered in Full* Vision Care - Hardware (Per two calendar years) $200 for frames, lenses & contact lenses $200 for frames, lenses & contact lenses Mental Health - Outpatient Office Visit DEDUCTIBLE WAIVED $30 Copay Deductible, then 50% Mental Health - Inpatient Facility Care Deductible, then 30% Transplants (12-month waiting period; $350,000 lifetime benefit) Organ & Bone Marrow Deductible, then 30% Not Covered * Benefits provided at 100% of allowable charges: not subjeect to deductible or coinsurance. ** 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 Problems viewing this page? Contact the webmaster.