Square Deal Remodeling
LifeWise Passport Silver HSA PPO 3000
1040052
HOW TO CONTACT US
Please call or write Our Customer Service staff for help with the following:
 Questions about the benefits of Your Plan;
 Questions about Your Claims;
 Questions or complaints about care or Services You receive; and
 Change of address or other personal information.
Customer Service - 1-800-596-3440
Mailing Address
Local and toll-free phone numbers:
Bend
1-800-596-3440
LifeWise Health Plan of Oregon
P O Box 7709
Bend, OR 97708-7709
TDD number for the hearing impaired
1-800-842-5357
Portland
(503) 295-6707
LifeWise Health Plan of Oregon
2020 SW Fourth Avenue, Suite 1000
Portland, OR 97201
1-800-926-6707
TDD number for the hearing impaired
1-800-842-5357
You'll find answers to most of Your questions about Your Plan in this benefit booklet. You can also explore Our
Web site at www.lifewiseor.com anytime You want to:
 Learn more about how to use Your Plan;
 Locate a health care provider near You;
 Gain knowledge about diseases, illnesses, medications, treatment, nutrition, fitness and many other health
topics.
 You can also call Our Customer Service staff at the numbers listed above. We are happy to answer Your
questions and appreciate any comments You want to share.
Group Name:
Effective Date:
Group Number:
Plan:
Certificate Form Number:
LWO SG 01-2014 Rev. 01-2016
Square Deal Remodeling
January 1, 2016
1040052
LifeWise Passport Silver HSA PPO 3000
LWO SG 01-2016
LifeWise Passport Silver HSA PPO 3000
INTRODUCTION
This Benefit Booklet is for Members enrolled in this Plan. This Benefit Booklet describes the benefits and other
terms of this Plan. It replaces any other Benefit Booklet You may have received.
We know that healthcare Plans can be hard to understand and use. We hope this Benefit Booklet helps You
understand how to get the most from Your benefits.
The benefits and provisions described in this Plan are subject to the terms of the master group contract (contract)
issued to the employer. The employer is the firm, corporation or partnership that contracts with Us. This benefit
booklet is a part of the contract on file at the employer’s office.
This plan will comply with state and federal laws. If clarifications are made by regulators, this plan will comply
even if they are not stated or are in conflict with a statement made in this benefit booklet.
This Plan meets the requirements of a high deductible health plan for use with a health savings account. A health
savings account is not a requirement for enrollment or eligibility on this Plan. LifeWise is not an administrator,
trustee or fiduciary of any health savings account with this Plan. This Plan is not intended to override health
savings account requirements. Services allowed as a deduction under the health savings account may not be a
Covered Service under this Plan. Please contact Your health savings account administrator if You have
questions. If the requirements for high deductible health plans are changed by law or regulation, We will
administer this Plan according to those changes even though they are not yet described in this Benefit Booklet.
Translation Services
If you need an interpreter to help with oral translation services, please call us. The Customer Service Area will be
able to guide you through the service.
HOW TO USE THIS BENEFIT BOOKLET
Every section in this Benefit Booklet has important information. You may find that the sections below are
especially useful.
 How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are inside
the front cover
 Summary of Your Costs – Lists your costs for covered services
 Important Plan Information – Describes deductibles, Copays, Coinsurance, out-of-pocket maximums and
Allowed Amounts
 How Providers Affect Your Costs – How using an in-network provider affects Your benefits
 Prior Authorization and Emergency Admission Notifications – Describes Our Prior Authorization and
Emergency Admission Notifications provision
 Utilization Review – Describes Our Utilization Review provision
 Personal Health Support Programs – Describes Our Personal Health Support Programs provision
 Continuity of Care – Describes how to continue care at the in-network level of benefits when a provider is no
longer in the network
 Covered Services – A detailed description of what is covered
 Employee Wellness – Describes a program to help improve wellness
 Exclusions – Describes Services that are not covered
 Other Coverage – Describes how benefits are paid when You have other coverage or what You must do when
a third party is responsible for an injury or Illness
 Sending Us a Claim –Instructions on how to send in a Claim
 Grievance and Appeals – What to do if You want to share ideas, ask questions, file a complaint, or submit an
appeal
 Eligibility and Enrollment – Describes who can be covered
 Termination of Coverage – Describes when coverage ends
LWO SG 01-2014 Rev. 01-2016
LifeWise Passport Silver HSA PPO 3000
 Continuation Coverage – Describes how You can continue coverage after Your group Plan ends
 Other Plan Information – Lists general information about how this Plan is administered and required state and
federal notices
 Definitions – Meanings of words and terms used
LWO SG 01-2014 Rev. 01-2016
LifeWise Passport Silver HSA PPO 3000
TABLE OF CONTENTS
SUMMARY OF YOUR COSTS.....................................................................................................................1
IMPORTANT PLAN INFORMATION ...........................................................................................................7
Calendar Year Deductible ......................................................................................................................7
Out-of-Pocket Maximum.........................................................................................................................7
Allowed Amount ..................................................................................................................................... 7
HOW PROVIDERS AFFECT YOUR COSTS ...............................................................................................8
Network Providers .................................................................................................................................. 8
Care Outside the Service Area...............................................................................................................9
PRIOR AUTHORIZATION AND EMERGENCY ADMISSION NOTIFICATION...........................................9
UTILIZATION REVIEW .............................................................................................................................. 11
Personal Health Support Programs......................................................................................................11
Continuity of Care................................................................................................................................. 11
COVERED SERVICES ............................................................................................................................... 12
Common Medical Services...................................................................................................................12
Prescription Drugs ................................................................................................................................ 14
Other Covered Services .......................................................................................................................24
Employee Wellness .............................................................................................................................. 27
EXCLUSIONS............................................................................................................................................. 27
OTHER COVERAGE.................................................................................................................................. 30
Coordination Of Benefits ......................................................................................................................30
Third Party Liability ............................................................................................................................... 33
SENDING US A CLAIM.............................................................................................................................. 34
GRIEVANCE AND APPEALS....................................................................................................................35
ELIGIBILITY AND ENROLLMENT ............................................................................................................38
When Coverage Begins .......................................................................................................................39
Enrollment Provisions for Late and Special Enrollees..........................................................................40
TERMINATION OF COVERAGE ...............................................................................................................42
CONTINUATION OF COVERAGE.............................................................................................................43
OTHER PLAN INFORMATION ..................................................................................................................44
DEFINITIONS ............................................................................................................................................. 47
LWO SG 01-2014 Rev. 01-2016
LifeWise Passport Silver HSA PPO 3000
SUMMARY OF YOUR COSTS
This is a summary of Your costs for Covered Services. Your costs are subject to the all of the following:
 The allowed amount. This is the most this Plan allows for a Covered Service.
 The deductible. This is the amount You pay before Our cost share of the allowed amount is applied.
Deductibles are waived for some Services. The amount of the deductible for this Plan is:
In-network Providers
Individual deductible:
$3,000 per Member
Family deductible:
$6,000 per Family
Out-of-network Providers
Individual deductible:
$6,000 per Member
Family deductible:
$12,000 per Family
 The out-of-pocket maximum. This is the most You pay each Year for Services from in-network providers.
Individual out-of-pocket maximum:
$4,800 per Member
Family out-of-pocket maximum:
$9,600 per Family
 The out-of-pocket maximum. This is the most You pay each Year for Services from out-of-network providers.
Individual out-of-pocket maximum:
$9,600 per Member
Family out-of-pocket maximum:
$19,200 per Family
 Prior authorization. Some Services must be authorized by Us in writing and before You get them. See the
Prior Authorization and Emergency Admission Notification section for details.
 The conditions, time limits and maximum limits described in this contract. Some Services have special rules.
See Covered Services for these details.
YOUR COSTS
(of the allowed amount)
COVERED SERVICES
IN-NETWORK
PROVIDERS
OUT-OF-NETWORK
PROVIDERS
COMMON MEDICAL SERVICES
Office and Clinic Visit
 Office Visit
20%
50%
 Facility charges
You may have additional costs for things such as xrays, lab and therapeutic injections. See those
Covered Services for details.
20%
50%
 Routine exams, well baby care and immunizations
$0, deductible waived
Not covered
 Women’s pelvic exams, pap smear, clinical breast
exams and mammograms
$0, deductible waived
50%
Preventive Care
Limited to how often You can get them based on Your
age and if You are male or female.
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LifeWise Passport Silver HSA PPO 3000
LifeWise Health Plan of Oregon
Square Deal Remodeling/1040052
YOUR COSTS
(of the allowed amount)
COVERED SERVICES
IN-NETWORK
PROVIDERS
OUT-OF-NETWORK
PROVIDERS
COMMON MEDICAL SERVICES
 Pregnant women’s Services, electric breast pumps
and supplies
$0, deductible waived
50%
 Men’s prostate screening, including PSA
$0, deductible waived
50%
 Colon cancer screening, outpatient lab and
radiology for preventive screening and tests
$0, deductible waived
50%
 Flu shots, flu mist, immunizations for shingles,
pneumonia and Pertussis at a pharmacy
$0, deductible waived
0%, deductible waived
 Contraceptive management, elective sterilization,
tubal ligation.
$0, deductible waived
50%
 Nicotine dependency programs and health
education for conditions other than diabetes
$0, deductible waived
Not covered
 Fall prevention age 65 and older
$0, deductible waived
Not covered
 Diabetes health education
$0, deductible waived
Not covered
 Nutritional therapy
$0, deductible waived
50%
 Routine exams limited to one per Year
20%, deductible waived
20%, deductible waived
 Frames, limited to one pair every two Years
0%, deductible waived
0%, deductible waived
 Lenses (standard and non-correction) limited to
one pair every two Years
0%, deductible waived
0%, deductible waived
 Contact lenses in lieu of glasses, limited to one
pair every two Years
0%, deductible waived
0%, deductible waived
 Hearing Aids and hardware, limited to Members
under the age of 19 or Dependents age 19 up to
age 26. Limited to one hearing aid per impaired ear
every three years.
Diagnostic X-ray, Lab and Imaging
X-ray and lab, including MRI, MRA, PET and CT
Scans
0%, deductible waived
0%, deductible waived
20%
50%
 Preventive drugs, limited to prescribed drugs
required by health care reform and to HSA generic
preventive drugs
$0, deductible waived
Not covered
 Nicotine cessation drugs, oral generic and single
source brand name contraceptive drugs and
devices
$0, deductible waived
Not covered
 Formulary generic drugs
20%
Not covered
 Formulary preferred brand name drugs
20%
Not covered
 Formulary non-preferred brand name drugs
20%
Not covered
Pediatric Care
 Vision care, limited to members up to age 19
Prescription Drugs– Retail Pharmacy
Limited up to a 90-day supply. Some contraceptives
may be allowed up to a 12-month supply.
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LWO SG 01-2016 SYC
LifeWise Passport Silver HSA PPO 3000
LifeWise Health Plan of Oregon
Square Deal Remodeling/1040052
YOUR COSTS
(of the allowed amount)
COVERED SERVICES
IN-NETWORK
PROVIDERS
OUT-OF-NETWORK
PROVIDERS
COMMON MEDICAL SERVICES
Prescriptions – Mail Order Pharmacy
Limited up to a 90-day supply. Some contraceptives
may be allowed up to a 12-month supply.
 Preventive drugs, limited to prescribed drugs
required by health care reform, and to HSA generic
preventive drugs
$0, deductible waived
Not covered
 Nicotine cessation drugs, oral generic and single
source brand name contraceptive drugs and
devices
$0, deductible waived
Not covered
 Formulary generic drugs
20%
Not covered
 Formulary preferred brand name drugs
20%
Not covered
 Formulary non-preferred brand name drugs
20%
Not covered
Prescriptions – Specialty Pharmacy
Limited up to a 30-day supply for formulary, generic,
and brand name drugs.
20%
Not covered
Outpatient Surgery Services
Hospitals, ambulatory surgery center, doctor’s office
and the professional Services
20%
50%
Vasectomy
20%
50%
Emergency Room
Includes emergency room and Hospital Urgent Care
facilities.
The Coinsurance is waived if You are admitted as an
Inpatient through the emergency room.
20%
Emergency room Physician
20%
Emergency Ambulance Services
Emergency air and ground ambulance Services
20%
Urgent Care Centers
Includes facility and professional Services
You may have additional costs for things such as xrays, lab and therapeutic injections. See those
Covered Services for details.
20%
50%
Urgent Care Centers, facility based
You may have additional costs for things such as xrays, lab and therapeutic injections. See those
Covered Services for details.
See Emergency Room
Hospital Services
20%
50%
 Office visits
20%
50%
 Outpatient facility Services
20%
50%
 Inpatient Hospital, partial hospitalization, residential
20%
50%
Mental Health, Behavioral Health and Substance
Abuse
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LWO SG 01-2016 SYC
LifeWise Passport Silver HSA PPO 3000
LifeWise Health Plan of Oregon
Square Deal Remodeling/1040052
YOUR COSTS
(of the allowed amount)
COVERED SERVICES
IN-NETWORK
PROVIDERS
OUT-OF-NETWORK
PROVIDERS
COMMON MEDICAL SERVICES
facilities
Maternity and Newborn Care
Prenatal, postnatal care, delivery and Inpatient care.
20%
50%
Home Health Care
20%
50%
Hospice Care
Respite care is limited to 5 consecutive days up to a
lifetime maximum of 30 days.
20%
50%
 Outpatient office Services
20%
50%
 Inpatient facility Services
20%
50%
 Outpatient facility Services
20%
50%
 Outpatient office Services
20%
50%
 Inpatient facility Services
20%
50%
 Outpatient facility Services
20%
50%
Cardiac Rehabilitation
Limited to 36 sessions per Year.
20%
50%
Skilled Nursing Facility
Limited to 60 days per Year.
20%
50%
Home Medical Equipment (HME), Supplies,
Devices, Prosthetics and Orthotics
Foot Orthotics for conditions other than diabetes are
limited to 1 pair or 2 units per Year.
20%
50%
Rehabilitation Therapy
Limited to a combined 30 Outpatient visits and a
combined 30 Inpatient visits/days per Year. An
additional 30 visits will be allowed for stroke and
spinal cord/head injury. Limits do not apply to Mental
Health Services.
Habilitation Therapy
Limited to physical therapy, occupational therapy and
speech therapy up to a combined 30 Outpatient visits
and a combined 30 inpatient days per Year. An
additional 30 visits per condition may be allowed for
stroke and spinal cord/head injury. Limits do not
apply to Mental Health Services.
YOUR COSTS
(of the allowed amount)
COVERED SERVICES
IN-NETWORK
PROVIDERS
OUT-OF-NETWORK
PROVIDERS
OTHER COVERED SERVICES (Alphabetical Order)
Allergy Testing and Treatment
Covered based on the
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LWO SG 01-2016 SYC
50%
LifeWise Passport Silver HSA PPO 3000
LifeWise Health Plan of Oregon
Square Deal Remodeling/1040052
YOUR COSTS
(of the allowed amount)
COVERED SERVICES
IN-NETWORK
PROVIDERS
OUT-OF-NETWORK
PROVIDERS
OTHER COVERED SERVICES (Alphabetical Order)
type of Services You get
Biofeedback
Covered based on the
type of Services You get
50%
 Chemotherapy includes infusion and injectable
drugs
20%
50%
 Prescribed oral chemotherapy drugs
20%, deductible waived
50%
Clinical Trials
Covered based on the
type of Services You get
50%
Craniofacial Anomalies
Covered based on the
type of Services You get
50%
Dental Accidents – Outpatient Visits
Covered based on the
type of Services You get
50%
Dental Anesthesia - Outpatient
Limited to the following:
20%
50%
Dialysis Services
Dialysis Services for End-Stage Renal Disease
(ESRD)
20%
50%
Foot Care
Routine care that is Medically Necessary for treatment
of diabetes
20%
50%
Infusion Therapy (Outpatient)
20%
50%
Mastectomy and Breast Reconstruction
Covered based on the
type of Services You get
50%
$25 copay, deductible
waived
0%, deductible waived
$25 copay, deductible
waived
0%, deductible waived
Sleep Studies - Outpatient
20%
50%
Telehealth Virtual Care Services
20%
50%
See Office and Clinic
Visits
20%
50%
Chemotherapy and Radiation Therapy
 Members under age 7 with a disability
 Members with a medical condition and it is not safe
to do the treatment outside a Hospital or ambulatory
surgical center.
Routine Vision Exam/Care
Limited to Members age 19 and older
 Exams, limited to one exam per Year
 Frames and lenses, contact lenses, limited to $150
per Year
Telemedicine Services
 Office visits
 Facility costs
5
LWO SG 01-2016 SYC
50%
LifeWise Passport Silver HSA PPO 3000
LifeWise Health Plan of Oregon
Square Deal Remodeling/1040052
YOUR COSTS
(of the allowed amount)
COVERED SERVICES
IN-NETWORK
PROVIDERS
OUT-OF-NETWORK
PROVIDERS
OTHER COVERED SERVICES (Alphabetical Order)
Therapeutic Injections
20%
50%
 Donor Covered Services
20%
Not covered
 Office Visits
20%
Not covered
 Inpatient facility, Outpatient care and related
Services
20%
Not covered
 Two round trip tickets, plus two weeks of
accommodations for travel and lodging expenses
per transplant
0%
0%
Transplants
6
LWO SG 01-2016 SYC
LifeWise Passport Silver HSA PPO 3000
LifeWise Health Plan of Oregon
Square Deal Remodeling/1040052
IMPORTANT PLAN INFORMATION
OUT-OF-POCKET MAXIMUM
This Plan is a Preferred Provider Plan (PPO). Your
Plan provides You the flexibility to receive Covered
Services from providers without referrals. You have
access to one of the many providers included in Our
network of providers for Covered Services included in
Your Plan. You also have access to facilities,
emergency rooms, surgical centers, equipment
vendors or pharmacies providing Covered Services
throughout the United States and Emergency
Services wherever You may travel.
If You and one or more of Your Dependents are
enrolled in this Plan, the family out-of-pocket
maximum will apply.
Individual Out-of-Pocket Maximum
This section includes important information about this
Plan, such as Your deductibles, out-of-pocket
maximum and the allowed amount.
This Plan includes an individual out-of-pocket
maximum for Covered Services when You use innetwork providers as shown on the Summary of Your
Costs. The out-of-pocket maximum is a limit on how
much You pay each Year. The deductibles,
Coinsurance and Copays You pay count toward this
limit. After You meet the out-of-pocket maximum,
benefits for Covered Services are paid at 100% of the
allowed amount for the rest of that Year.
CALENDAR YEAR DEDUCTIBLE
Family Out-of-Pocket Maximum
A deductible is the amount You pay for Covered
Services for each Year before this Plan provides
benefits.
This Plan includes a family out-of-pocket maximum
for Covered Services when You use in-network
providers as shown on the Summary of Your Costs.
The out-of-pocket maximum is a limit on how much
Your family pays each Year. The deductibles,
Coinsurance and Copays Your family pays count
toward this limit. After Your family out-of-pocket
maximum has been met, benefits for Covered
Services are provided at 100% of the allowed amount
for the rest of that Year.
If You and one or more of Your Dependents are
enrolled in this Plan, the family deductible will apply.
Individual Deductible
This Plan includes an individual deductible when You
see in-network providers and a separate individual
deductible when You see out-of-network providers.
After You pay this amount, this Plan will begin paying
for Your Covered Services. See the Summary of
Your Costs for Your individual deductible amount.
Expenses that do not apply to the individual or family
out-of-pocket maximum include:
 Charges above the allowed amount
Family Deductible
 Services above the any benefit maximum limit or
durational limit
This Plan includes a family deductible when You see
in-network providers and a separate family deductible
when You see out-of-network providers. This Plan
limits the total deductible that must be met by all
Members. The family deductible is the aggregate
amount a family must pay before We begin to provide
benefits. See the Summary of Your Costs for the
family deductible amounts.
 Services not covered by this Plan
 Covered Services or benefits that do not apply to
the out-of-pocket maximum. These are shown on
the Summary of Your Costs.
 Covered Services provided by out-of-network
providers
 Services that are not prior authorized
The individual and family deductibles, if any, are
subject to the following:
ALLOWED AMOUNT
 Deductibles accrue during a Year, January 1
through December 31
This Plan provides benefits based on the allowed
amount for Covered Services. The allowed amount is
described below:
 There is no carry over provision. Amounts credited
to Your deductible during the current Year will not
count toward the next Year’s deductible.
NON-EMERGENCY SERVICES
In-Network Providers
 Amounts credited to the deductible will not be more
than the allowed amount
The allowed amount is the fee that LifeWise has
negotiated with its in-network providers for Covered
Services.
 Copays are not applied to the deductible
 Amounts credited toward the deductible do not
accrue to benefits with a dollar maximum
Out-of-Network Providers
 Amounts credited toward the deductible accrue to
benefits with visit limits
The allowed amount is the lesser of the following:
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LWO SG 01-2014 Rev. 01-2016
LifeWise Passport Silver HSA PPO 3000
LifeWise Health Plan of Oregon
Square Deal Remodeling/ 1040052
 The provider’s billed charge
 Pediatrics
 No less than 125% of the fee schedule determined
by the Centers for Medicare and Medicaid Services
(CMS). LifeWise will use fee schedules from CMS
in setting the allowed amount.
 Geriatric medicine
 Nurse practitioners
 OB/GYN
 Physician Assistants
In the event CMS does not have a fee for a given
Service, We will request additional information from
Your provider. We will evaluate this information to
determine the amount that CMS would reimburse for
similar Services. The allowed amount will be the
lesser of the amount that CMS would reimburse for
similar Services or the out-of-network provider's billed
charges.
 Naturopaths
Please see the Summary of Your Costs for cost-share
information.
NETWORK PROVIDERS
In-Network Providers
In-network providers are networks of Hospitals,
Physicians, Specialists and other providers that We
contract with to provide medical Services at a
negotiated fee. We have in-network providers in all
categories of Services, such as laboratory and x-ray
Specialists and medical specialties.
EMERGENCY SERVICES
Consistent with the requirements of the Affordable
Care Act (federal health care reform) the allowed
amount will be the greater of the following:
 The median amount in-network providers have
agreed to accept for the same Services
You benefit in two ways when You receive Covered
Services from an in-network provider. Your medical
bills will be reimbursed at a higher percentage (the innetwork provider benefit level), and Our in-network
providers will not charge more than the allowed
amount. This means, the amount You pay of the
charges for Covered Services will be lower.
 The amount Medicare would allow for the same
Services
 The amount calculated by the same method the
Plan uses to determine payment to out-of-network
providers
In addition to Your deductible, Copay and
Coinsurance, You will be responsible for charges
received from out-of-network providers above the
allowed amount.
Contracted Providers Who Offer Unique Services
We have contracted with some health care systems of
providers to provide unique Services that are not
available from Our network of contracted providers.
We contract with these health care systems to provide
Covered Medical Services at negotiated fees. When
these providers offer their unique Services to Our
Members, We will allow their charges at the highest
(in-network) benefit level and You will not be balance
billed for any charge over the allowed amount.
If You have questions about this information, please
call Us at the number listed on Your LifeWise ID card.
HOW PROVIDERS AFFECT YOUR
COSTS
Throughout this section You will find information on
how to control Your out-of-pocket cost and how the
providers You see for Covered Services can affect
Your Plan benefits.
Out-of-Network Providers
Out-of-network providers are providers that do not
have a contract with LifeWise. Your medical bills will
be reimbursed at the lower level of benefits (out-ofnetwork) and the provider may bill You for charges
above the allowed amount. This means that Your
out-of-pocket costs will be higher because Your
benefit level is lower and You will be responsible for
any charges over the allowed amount.
We believe wellness and overall health is enhanced
by working closely with one provider. Although this
Plan does not require the use or selection of a
primary care provider (PCP) or a referral for specialty
care, We encourage You to select a PCP at the time
You enroll in this Plan and notify Us of Your selection.
Selecting a PCP gives You a partner to help You
manage Your care.
How to Select a LifeWise In-Network Provider
A list of Our in-network providers is available in Our
provider directory. These providers are listed by
geographical area, specialty and in alphabetical order
to help You select a provider that is right for You or
Members of Your family. We update this directory
regularly, but it is subject to change. We suggest that
You call Us for current information and to verify that
A PCP must be an in-network provider and choices
include the following providers:
 General practice
 Family practice
 Internal medicine
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LWO SG 01-2014 Rev. 01-2016
LifeWise Passport Silver HSA PPO 3000
LifeWise Health Plan of Oregon
Square Deal Remodeling/ 1040052
Your provider, their office location or provider group is
included in the LifeWise network before You get
Services.
How to Ask for Prior Authorization
This Plan has a specific list of Services that must
have Prior Authorization with any provider. Before
You receive Services, We suggest that You review
the list of Services requiring Prior Authorization. You
can get a detailed list of medical Services requiring
Prior Authorization by calling Customer Service at the
number on the back of Your ID card or on Our
website at lifewiseor.com.
Services From In-Network Providers: It is Your innetwork provider’s responsibility to get Prior
Authorization for planned Services and before
Services are provided. Your in-network provider can
call Us at the number listed on Your ID card to
request a Prior Authorization.
Services from Out-of-Network Providers: It is Your
responsibility to get Prior Authorization for any of the
Services on the Prior Authorization list when You see
an out-of-network provider. You or Your out-ofnetwork provider can call Us at the number listed on
Your ID card to request a Prior Authorization.
Responding to Prior Authorizations
The LifeWise Provider Directory is available any time
on Our website at lifewiseor.com. You may also
request a copy of this directory by calling Customer
Service at the number located in the front of this
Benefit Booklet or on Your LifeWise ID card.
The Covered Services listed below are only available
from in-network providers, as shown on the Summary
of Your Costs.
 Other Health Education Services
 Prescription Drugs
 Preventive Care
 Tobacco Use Cessation Programs
 Transplants
CARE OUTSIDE THE SERVICE AREA
LifeWise Members have access to a nationwide
network of providers when outside the Service Area.
Our Service Area is Oregon. These providers will not
charge You for amounts over the allowed amount,
and they will submit Claims directly to Us.
We will respond to a request for Prior Authorization
within 2 business days of receipt of all information
necessary to make a decision. If Your situation is
clinically urgent (meaning that Your life or health
would be put in serious jeopardy if You did not receive
treatment right away), You may request to have your
Prior Authorization reviewed as expedited. Once We
have been given all the necessary information to
make a decision. We will provide Our decision in
writing.
The availability of these providers may vary by
location. For more information on care outside the
Service Area, contact Customer Service.
PRIOR AUTHORIZATION AND
EMERGENCY ADMISSION
NOTIFICATION
The Prior Authorization will be binding to Us when
related to eligibility and obtained no more than five
business days before the date of Service. Our Prior
Authorization will be valid for 30 calendar days for
benefit coverage and Medical Necessity
determinations. This 30 calendar day period is
subject to Your continued coverage under the Plan. If
You do not receive the Services within that time, You
or Your provider will have to ask Us for another Prior
Authorization.
Services that must be Prior Authorized
The following are types of Services that require Prior
Authorization. You can see the detailed list on Our
website lifewiseor.com or You can call Customer
Service.
The following types of Services require Prior
Authorization:
Your coverage for some Services depends on
whether the Service is approved by Us before You
receive it. This process is called Prior Authorization.
A planned Service is reviewed to make sure it is
Medically Necessary and eligible for coverage under
this Plan. We will let You know in writing if the
Service is authorized. We will also let You know if the
Service is not authorized and the reasons why. If You
disagree with the decision, You can request an
appeal.
See the Grievances and Appeals section or call us.
There are three situations where Prior Authorization is
required:
 Before You receive certain medical Services or
prescription drugs
 Before You schedule a planned admission to
certain inpatient facilities
 Planned Inpatient admission into Hospitals, Skilled
Nursing Facilities, and rehabilitation facilities
 When You want to receive the higher benefit level
for Services You receive from an out-of-network
provider
 Non-emergency ground, air, or ambulance
transport
 Transplant and donor services
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 Injectable medications You get from a healthcare
provider’s office
may also view Our list of Prescription Drugs that
require Prior Authorization through the Member portal
on Our website at lifewiseor.com. Once You “Signin”, please go to “My Plan Information” then, select
the “Pharmacy” tab, and finally You’ll select “View
drugs that require Prior Authorization”.
 Prosthetics and Orthotics other than foot Orthotics
or orthopedic shoes
 Reconstructive surgery
 Home Medical Equipment (HME), costing $500 or
more
You can also find the Prior Authorization form that
Your Physician can completes and sends to
Pharmacy Services with their request for a Prior
Authorization. Sometimes You may not know if a
Prescription Drug needs Prior Authorization. For
example, You may go directly from Your provider’s
office to the pharmacy with a new prescription. If the
pharmacy tells you that the Prescription Drug Your
provider prescribed requires Prior Authorization, You
or Your pharmacy should call Your provider to let
them know. Your provider will then need to fax Us a
completed Prior Authorization form for review.
 Selected surgical, medical therapeutic, and
diagnostic procedures
 Outpatient advanced imaging, such as MRI, CT,
and echocardiograms
 Some Outpatient Services. See the detailed list on
Our website at lifewiseor.com.
 Certain Prescription Drugs. See the Pharmacy
section on our website at lifewiseor.com.
Prior Authorization Penalty
While your provider’s request is in review, You have
the option to buy the Prescription Drug before it is
Prior Authorized, but You must pay the full cost.
Once the Prior Authorization is reviewed, if the drug is
authorized after You bought it, You can send Us a
Claim for reimbursement. However, the amount of
reimbursement will be based on the allowed amount.
See the Sending Us A Claim section for details.
For Services from In-Network Providers
In-network providers will get a Prior Authorization for
You. You should verify with Your provider that a Prior
Authorization request has been approved in writing by
Us before You receive the Services.
For Services From Out-of-Network Providers
It is Your responsibility to get Prior Authorization for
any Services on the Prior Authorization list when You
see an out-of-network provider. If You do not get
Prior Authorization, the Services will not be covered.
The out-of-network provider can bill You and You will
have to pay the total cost for the Services. Your costs
for this penalty do not count toward Your Plan
deductibles and out-of-pocket maximum.
Non-Emergency Services from Out-of-Network
Providers
There may be times when You want to see an out-ofnetwork provider for non-Emergency Services. In
some cases out-of-network benefits may be paid at
the in-network cost share if the Services are Medically
Necessary and only available from an out-of-network
provider. You must ask for a Prior Authorization
before You see the out-of-network provider. The Prior
Authorization request must include the following:
Services listed below are not subject to a Prior
Authorization penalty:
 Emergency hospital admissions. See Emergency
Hospital Admission Notification described below.
 A statement that the out-of-network provider has
unique skills that are Medically Necessary for Your
care
 Prescription Drugs. See Prior Authorization for
Prescription Drugs described below.
 You cannot get the same care from an in-network
provider
 Non-Emergency Services from out-of-network
providers. See Non-Emergency Services From
Out-of-Network Providers described below.
 Medical records supporting Your request
If We approve Your request, the Services will be
covered at the in-network cost share. In addition to
Your usual cost share, You will also pay any amounts
over the allowed amount.
Prior Authorization for Prescription Drugs
Certain Prescription Drugs require a Prior
Authorization before You get them at a pharmacy.
You or Your provider can ask for a Prior Authorization
by faxing a Prior Authorization form to Us. This form
is in the Pharmacy section of Our website at
lifewiseor.com.
If there are in-network providers who can give You the
same care, Your Prior Authorization request will not
be approved. Your costs for these Services will be at
the out-of-network provider cost share.
Your provider can tell You if a new Prescription Drug
requires Prior Authorization. Your provider can check
with Us to see if Prior Authorization is required. You
Emergency Admission Notification
The following Services do not need authorization, but
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they have separate requirements:
PERSONAL HEALTH SUPPORT
PROGRAMS
 Emergency Hospital admissions, including
admissions for drug or alcohol Detoxification. They
do not require Prior Authorization, but You must
notify Us soon as reasonably possible.
LifeWise’s personal health support programs are
designed to help make sure Your health care and
treatment improve Your health. You will receive
individualized and integrated support based on Your
specific needs. These Services could include working
with You and Your doctor to ensure appropriate and
cost-effective medical care, to consider effective
alternatives to hospitalization, or to support both of
You in managing chronic conditions.
 If You are admitted to an out-of-network Hospital
due an Emergency Medical Condition, those
Services will always be covered under Your innetwork cost share. We will continue to cover
those Services until You are medically stable and
can safely transfer to an in-network Hospital. If
You chose to remain at the out-of-network Hospital
after You are medically stable to transfer, coverage
will revert to the out-of-network cost share of
benefits. We pay for Covered Services based on
Our allowed amount. If the Hospital is not
contracted with Us, You may be billed for charges
over the allowed amount.
Your participation in a treatment plan through Our
personal health support programs are voluntary. To
learn more about these programs, contact Customer
Service at the number listed on your LifeWise ID card.
CONTINUITY OF CARE
 Childbirth admission to a Hospital, or admissions
for newborns that need medical care at birth. They
do not require Prior Authorization, but You must
notify Us as soon as reasonably possible.
Admissions to an out-of-network Hospital will be
covered at the out-of-network cost share of
benefits, unless the admission was an emergency.
You may be able to continue to receive Covered
Services from an in-network provider for a limited
period of time at the in-network benefit level after the
provider ends their contract with LifeWise. To be
eligible for continuity of care You must be covered
under this Plan, in an active treatment plan and
receiving Covered Services from an in-network
provider at the time the provider ends his/her contract
with LifeWise. The treatment must be Medically
Necessary and You and this provider agree that it is
necessary for You to maintain continuity of care.
UTILIZATION REVIEW
LifeWise has developed or adopted guidelines and
medical policies that outline clinical criteria used to
make Medical Necessity determinations. The clinical
criteria is reviewed annually and is updated as
needed to ensure Our determinations are consistent
with current medical practice standards and follows
national and regional norms. Practicing community
doctors are involved in the review and development of
Our internal criteria. You or Your provider may
request a copy of the criteria used to make a Medical
Necessity decision for a particular condition,
treatment or procedure. To obtain the information,
please send Your request to:
We will not provide continuity of care if Your provider:
 Will not accept the reimbursement rate applicable
at the time the provider contract terminates
 Retired
 Died
 No longer holds an active license
 Relocates out of the Service Area
 Goes on sabbatical
 Is prevented from continuing to care for patients
because of other circumstances
LifeWise
Utilization Review
P.O. Box 7709
Bend, OR 97708
 Terminates the contractual relationship in
accordance with provisions of contract relating to
quality of care and exhausts his/her contractual
appeal rights
1-800-722-3372
Fax 800-843-1114
We will not provide continuity of care if You are no
longer covered under this Plan.
LifeWise reserves the right to deny payment for
Services that are not Medically Necessary or that are
considered Experimental/Investigational. A decision
by LifeWise following this review may be appealed in
the manner described in the Grievance and Appeals
section. When there is more than one alternative
available, coverage will be provided for the least
costly among medically appropriate alternatives.
We will notify You no later than 10 days after Your
provider’s LifeWise contract ends if We reasonably
know that You are under an active treatment plan. If
We learn that You are under an active treatment plan
after Your provider’s contract termination date, We
will notify You no later than the 10th day after We
become aware of this fact.
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To receive continuity of care, You must request
continuity of care from Us.
setting. This Plan covers Inpatient care only when
You cannot get the Services in a less intensive
setting.
You can call Us at 1-800-722-3372 or send Your
request to:
 The Service is not excluded
 The provider is working within the scope of their
license or certification
LifeWise
Utilization Review
P.O. Box 7709
Bend, OR 97708
1-800-722-3372
Fax 800-843-1114
This Plan may exclude or limit benefits for some
Services. See the specific benefits in this section and
the Exclusions section for details.
Benefits for Covered Services are subject to the
following:
Duration of Continuity Of Care
If You are eligible for continuity of care, You will get
continuity of care until the earlier of the following:
 Copays
 The day after You complete the active course of
treatment entitling You to continuity of care
 Coinsurance
 Deductibles
 Benefit limits
 The 120th day after We notified You that Your
provider’s contract ended, or the date Your request
for continuity of care was received or approved by
Us, whichever is earlier
 Prior Authorization. Some Services must be
authorized in writing by Us before You get them.
These Services are identified in this section. For
more information see the Prior Authorization and
Emergency Admission Notification section.
 If You are pregnant and become eligible for
continuity of care after commencement of the
second trimester of the pregnancy, You will receive
continuity of care until the later of:
 Medical and payment policies. The Plan has
policies used to administer the terms of the Plan.
Medical policies are generally used to further define
Medical Necessity or investigational status for
specific procedures, drugs, biologic agents,
devices, level of care or services. Payment policies
define our provider billing and payment rules. Our
policies are based on accepted clinical practice
guidelines and industry standards, accepted by
organizations like the American Medical
Association (AMA), other professional societies and
the Center for Medicare and Medicaid Services
(CMS). Our policies are available to You and Your
provider on Our website at lifewiseor.com or by
calling Customer Service.
 The 45th day after the birth
 As long as You continue under an active course
of treatment, but no later than the 120th day after
We notified You that Your provider’s contract
ended, or the date Your request for continuity of
care was received or approved by Us, whichever
is earlier
When continuity of care terminates, You may continue
to receive Services from this same provider; however,
We will pay benefits at the out-of-network benefit level
subject to the allowed amount. Please refer to the
How Providers Affect Your Costs for an illustration
about benefit payments. If We deny Your request for
continuity of care, You may request an appeal of the
denial. Please refer to the section titled Grievance
and Appeals for information on how to submit a
grievance review request.
If You have any questions regarding Your benefits
and how to use them, call Customer Service at the
number listed on the inside cover of this booklet or on
Your LifeWise ID card.
COMMON MEDICAL SERVICES
COVERED SERVICES
The Services listed in this section are covered as
shown on the Summary of Your Costs. Please see
the Summary of Your Costs for Your Copays,
deductible, Coinsurance and benefit limits.
This section describes the Services this Plan covers.
Covered Service means Medically Necessary
Services (see Definitions) and specified preventive
care Services You get when You are covered for that
benefit. This Plan provides benefits for Covered
Services only if all of the following are true when You
get the Services:
Office and Clinic Visits
This Plan covers professional office and home visits.
The visits can be for examination, consultation and
diagnosis of an Illness or injury by Your primary care
provider or a Specialist. Some Outpatient Services
You get from a Specialist must be Prior Authorized.
See the Prior Authorization and Emergency
 The reason for the Service is to prevent, diagnose
or treat a covered Illness, disease or injury
 The Service takes place in a Medically Necessary
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Admission Notification section for details.
The cost of the rental cannot be more than the
purchase price.
Primary Care Visits
 Prostate cancer screening. Includes digital rectal
exams and prostate-specific antigen (PSA) tests.
For this Plan, primary care providers include general
practice, family practice, internal medicine, pediatric,
geriatric and obstetrical and gynecology (OB/GYN)
Physicians, nurses, nurse practitioners and Physician
Assistants and naturopaths.
 Colon cancer screening. Includes exams,
colonoscopy, sigmoidoscopy, double contrast
barium enemas, removal of polyps in the colon and
fecal occult blood tests. Including anesthesia
services performed in connection with preventive
colonoscopy, when the attending provider
determines anesthesia is medically appropriate for
the individual.
Specialist Visits
For this Plan, a Specialist includes providers such as
surgeons, anesthesiologists, psychologists,
psychiatrists.
 Outpatient lab and radiology for preventive
screening and tests
You may have to pay a separate Copay or
Coinsurance for other Services You get during a visit.
This includes Services such as, but not limited to, xrays, lab work, therapeutic injections and office
surgeries.
 Routine immunizations and vaccinations as
recommended by Your Physician. You can also
get flu shots, flu mist, and immunizations for
shingles, pneumonia and Pertussis at a pharmacy
or other center.
Preventive Care
 Contraceptive management. Includes exams,
treatment You get at Your provider’s office,
emergency contraceptives, supplies and devices.
Tubal ligation is also covered. See Prescription
Drugs for prescribed oral contraceptives and
devices.
This Plan covers preventive care as described below.
Covered Services include preventive care Services
with a rating of “A” or “B” set by the United States
Preventive Task Force; immunizations recommended
by the Centers for Disease Control and Prevention
and as required by state law; and preventive care and
screenings recommended by the Health Resources
and Services Administration (HRSA).
 Health education and training for covered
conditions such as diabetes, high cholesterol and
obesity. Includes Outpatient self-management
programs, training, classes and instruction.
These Services have limits on how often You should
get them. These limits are based on Your age and if
You are a male or female. Some of the Services You
get as part of a routine exam may not meet these
guidelines. You can get a complete list of the
preventive care Services with these limits on Our
website at lifewiseor.com or call Us at the number
listed on Your LifeWise ID card for a list. You may
also review the federal guidelines at
www.uspreventiveservicestaskforce.org/uspstf/uspsa
brecs.htm and www.hrsa.gov/womensguidelines. This
list may be changed as required by law.
 Nutritional therapy. Includes Outpatient visits with
a Physician, nurse, pharmacist or registered
dietitians. The purpose of the therapy must be to
manage a chronic disease or condition such as
diabetes, high cholesterol and obesity.
 Preventive drugs required by federal law. See
Prescription Drugs.
 Approved tobacco use cessation programs
recommended by Your Physician. After You have
completed the program, please provide Us with
proof of payment and a completed reimbursement
form. You can get a reimbursement form on Our
website at lifewiseor.com. See Prescription Drugs
for covered drug benefits.
Covered Services include:
 Routine exams and well-baby care. Exams for
school, sports and employment are also covered.
 Women’s pelvic exam. Pap smear and clinical
breast exams.
 Fall prevention age 65 and older
 Mammograms. See Diagnostic Lab, X-ray and
Imaging for mammograms needed because of a
medical condition.
This benefit does not cover:
 Charges for Services that do not meet federal
guidelines. This includes Services provided more
often that the guidelines allow.
 Pregnant women’s Services such as breast feeding
counseling before and after delivery and maternity
diagnostic screening
 Oral prescription contraceptives dispensed and
billed by Your provider or a Hospital
 Electric breast pumps and supplies. Includes the
purchase of a non-Hospital grade breast pump or
12-month rental of a hospital grade breast pump.
 Over the counter (OTC) drugs, contraceptive
foams, jellies, sponges or condoms, unless
prescribed by a physician. See Prescription Drugs
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for prescribed oral contraceptives and devices.
provider.
 Gym memberships or exercise classes and
programs
The maximum benefit stated under the Summary of
Your Costs will be reviewed on January 1st of each
year based on the U.S. City Average Consumer Price
Index (CPI). The maximum benefit will be adjusted to
the CPI if the CPI is greater than the limit stated on
the Summary of Your Costs.
 Inpatient newborn exams while the child is in the
Hospital following birth. See Maternity and
Newborns for those Covered Services.
 Facility charges. When You get preventive
Services at a hospital based Physician’s office or
clinic and they charge a separate facility fee in
addition to the Service, You must pay Your
deductible and Coinsurance for the facility charges.
See Hospital Services for those costs.
The pediatric benefit does not cover:
 Batteries or cords for hearing aids
 Services for Members that do not meet the age
requirements
 Services not listed above as covered
 Lab and Pathology Services for colonoscopy or
sigmoidoscopy. See Diagnostic Lab, X-ray and
Imaging.
DIAGNOSTIC X-RAY, LAB AND IMAGING
This Plan covers diagnostic medical tests that help
find or identify diseases. Covered Services include
interpreting these tests for covered medical
conditions. Some diagnostic tests, such as MRA,
MRI, CT and echocardiograms require Prior
Authorization. See the Prior Authorization and
Emergency Admission Notification section for details.
 Physical exams for basic life or disability insurance
 Work-related disability evaluations or medical
disability evaluations
 The use of an anesthesiologist for monitoring and
administering general anesthesia for colon health
screenings, unless Medically Necessary when
specific medical conditions and risk factors are
present
Diagnostic tests include:
 Diagnostic imaging and scans like x-rays, MRIs
and EKGs
PEDIATRIC CARE
This Plan covers hearing and vision Services for
covered children as stated in the Summary of Your
Costs, unless otherwise stated below.
 Mammograms for a medical condition
Vision Exams and Glasses
 Barium enema
 MRI and ultrasound of the breast
 Men’s bone density screening for osteoporosis
This Plan covers routine eye exams and glasses and
includes the following:
 Lab Services
 Pathology tests
 Vision exams by an ophthalmologist or an
optometrist. A vision analysis may consist of
external and ophthalmoscope examination,
determination of the best corrected visual acuity,
determination of the refractive state, gross visual
fields, basic sensorimotor examination and
glaucoma screening.
This benefit does not cover:
 Preventive screening and tests. See Preventive
Care for Covered Services.
 Diagnostic Services from an Inpatient facility, an
Outpatient facility, or emergency room that are
billed with other Hospital or emergency room
Services. These Services are covered under
Inpatient, Outpatient or Emergency Room benefit.
 Glasses; frames and lenses
 Contact lenses in lieu of corrective vision hardware
 Diagnostic surgeries, biopsies and scope insertion
procedures. These Services covered under the
Outpatient Surgery Services benefit.
 Contact lenses required for medical reasons
This Plan covers pediatric vision Services until the
end of the month of the child’s 19th birthday, when all
eligibility requirements are met.
 Allergy tests. These Services are covered under
the Allergy Testing and Treatment benefit.
Hearing Aids
PRESCRIPTION DRUGS
This Plan covers hearing aids, ear molds and
attachments or accessories for the hearing aid or
device for Members under the age of 19 and
Dependents up to age 26. Benefits are provided when
the aids are prescribed, fitted and dispensed by a
licensed audiologist with the approval of Your
Prescription Drugs are covered when they are used
outside a medical facility. You must get these drugs
from a licensed pharmacist in a pharmacy licensed by
the state. Some Prescription Drugs require Prior
Authorization. See the Prior Authorization and
Emergency Admission Notification section for details.
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Prescription Drugs are also covered when drugs are
dispensed by a Physician at a rural health clinic for an
urgent medical condition if there is no pharmacy
within 15 miles of the clinic or if dispensed outside of
the normal business hours of any pharmacy within 15
miles of the clinic. For the purposes of this benefit,
urgent medical condition means a medical condition
that arises suddenly, is not life-threatening and
requires prompt treatment to avoid the development
of more serious medical problems.
strips, testing agents and lancets
 Drugs for shots that You give yourself
 Needles, syringes and alcohol swabs You use for
shots You give Yourself
 Glucagon emergency kits
 Inhalers, supplies and peak flow meters
 Drugs for nicotine dependency
 Human growth hormone drugs when Medically
Necessary
This Plan covers only formulary generic drugs and
formulary brand name drugs listed on the LifeWise
Formulary. Drugs not listed on the LifeWise formulary
are not covered by this Plan. Visit the Pharmacy
section on Our website at lifewiseor.com for a
complete list of current Prescription Drugs covered by
Your Plan. You can also contact Customer Service for
questions about covered drugs. The number for
Customer Service is on Your LifeWise ID card.
 Oral contraceptive drugs and devices such as
diaphragms and cervical caps
Pharmacy Management
Sometimes benefits for Prescription Drugs may be
limited to one or more of the following:
 A specific number of days’ supply or a specific drug
or drug dosage appropriate for a usual course of
treatment
Your provider may request that You get a nonformulary drug or a dose that is not on the drug list.
In some circumstances, a non-formulary drug may be
covered when one of the following is true:
 Certain drugs for a specific diagnosis
 Certain drugs from certain pharmacies, or You may
need to get prescriptions from an appropriate
medical Specialists or a specific provider
 There is no formulary drug or alternative available
 Step therapy, meaning You must try a generic drug
or a specified brand name drug first
 You cannot tolerate the formulary drug
 The formulary drug or dose is not safe or effective
for Your condition
These limitations are based on medical criteria, the
drug maker’s recommendations, and the
circumstances of the individual case. They are also
based on U.S. Food and Drug Administration
guidelines, published medical literature and standard
medical references.
You must also provide medical records to support
Your request. We will review Your request and let
You know in writing if it is approved. If approved,
Your cost will be as shown on the Summary of Your
Costs for Formulary generic and preferred brand
name drugs. If Your request is not approved, the
drug will not be covered.
Dispensing Limits
Benefits are limited to a certain number of days’
supply as shown in the Summary of Your Costs.
Sometimes a drug maker’s packaging may affect the
supply in some other way. We will cover a supply
greater than normally allowed under Your Plan if the
packaging does not allow a lesser amount. You must
pay a Copay for each limited days’ supply.
If You disagree with Our decision You may ask for an
appeal. See the Grievance and Appeals section for
details.
Covered Prescription Drugs
 FDA approved formulary Prescription Drugs and
vitamins. Federal law requires a prescription for
these drugs. They are known as “legend drugs.”
Preventive Drugs
 Off-label use of FDA-approved drugs. Off label oral
chemotherapy prescription drugs are not covered
under this benefit. See Chemotherapy and
Radiation Therapy
Your prescription benefit includes certain Outpatient
drugs as preventive drugs. This benefit includes
those drugs required by federal health care reform. It
also includes specific generic drugs that are taken
regularly to prevent a disease. It also includes drugs
taken to keep a specific disease or condition from
coming back after recovery. Preventive drugs do not
include drugs for treating an existing Illness, injury or
condition.
 See the Definitions section for Prescription Drugs
and off-label use
 Compound drugs, only when the main drug
ingredient is a covered Prescription Drug
 Oral drugs for controlling blood sugar levels, insulin
and insulin pens
You can get a list of covered preventive drugs by
calling Customer Service. You can also get this list in
the Pharmacy section on Our website at
 Throw-away diabetic test supplies such as test
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lifewiseor.com.
drugs need special handling, storage, administration,
or patient monitoring. This Plan covers these drugs
as shown in the Summary of Your Costs.
Using In-Network Pharmacies
When You use an in-network pharmacy, always show
Your LifeWise ID Card. As a Member, You will not be
charged more than the allowed amount for each
covered prescription or refill. The pharmacy will also
submit Your Claims to us. You only have to pay the
deductible, Copay or Coinsurance as shown in the
Summary of Your Costs.
Specialty drugs are high-cost often self-administered
injectable drugs. They are used to treat conditions
such as rheumatoid arthritis, hepatitis or multiple
sclerosis. We contract with specific specialty
pharmacies that specialize in these drugs. You and
Your provider must work with these specialty
pharmacies to get these drugs.
If You do not show Your LifeWise ID Card at an innetwork pharmacy, You will pay the full retail cost of
the prescription. Then You must send Us Your Claim
for reimbursement. Reimbursement is based on the
allowed amount, not retail costs. See Sending Us A
Claim for instructions.
This Plan covers specialty drugs only when they are
dispensed by Our in-network specialty pharmacies.
Visit the pharmacy section of Our website at
lifewiseor.com or call Customer Service for more
information.
This Plan uses the LifeWise Pharmacy Network.
This Plan does not cover Prescription Drugs from outof-network pharmacies.
This benefit does not cover:
 Drugs and medicines that You can legally buy over
the counter (OTC) without a prescription. OTC
drugs are not covered even if You have a
prescription. Examples include, but are not limited
to, non-prescription drugs and vitamins, herbal or
naturopathic medicines, and nutritional and dietary
supplements, such as infant formulas or protein
supplements.
This exclusion does not apply to OTC drugs that
are required by state or federal law.
Prescription Drug Volume Discount Program
Your Prescription Drug benefit program includes perclaim rebates that LifeWise received from its
pharmacy benefit manager. We consider these
rebates when We set the Premium charges, or We
credit them to administrative charges that We would
otherwise pay. These rebates are not reflected in
Your cost share. If the allowable charge for
Prescription Drugs is higher than the price We pay
Our pharmacy benefit manager for those Prescription
Drugs. LifeWise does one of two things with this
difference:
 Non-formulary generic and brand name drugs
 Drugs from out-of-network pharmacies
 We keep the difference and apply it to the cost of
Our operations and the Prescription Drug benefit
program
 Drugs from out-of-network specialty pharmacies
 Drugs for cosmetic use such as for wrinkles
 Drugs to promote or stimulate hair growth
 We credit the difference to premium rates for the
next benefit year
 Biological, blood or blood derivatives
 Any prescription refill beyond the number of refills
shown on the prescription or any refill after one
year from the original prescription
If Your Prescription Drug benefit includes a Copay,
Coinsurance calculated as a percentage, or a
deductible, the amount You pay and Your account
calculations are based on the allowed amount.
 Infusion therapy drugs or solutions, drugs requiring
parenteral administration or use, and injectable
medications. Exceptions to this exclusion are
injectable drugs for self-administration such as
insulin and glucagon and growth hormones. See
Infusion Therapy for covered infusion therapy
Services.
Refill
The Plan covers prescription refills only after You use
up 75% of Your medication, except as required by
law. The 75% is based on these two factors:
 The number of units and days’ supply You got on
the last refill
 Drugs dispensed for use in a health care facility or
provider’s office or take-home medications.
Exceptions to this exclusion are injectable drugs for
self-administration such as insulin and glucagon
and growth hormones.
 The total units or days’ supply You got for the same
medication in the 180-day period before the last
refill
Specialty Pharmacy Programs
 Immunizations. See Preventive Care.
The Specialty Pharmacy Program includes drugs that
are used to treat complex or rare conditions. These
 Drugs to treat infertility, to enhance fertility or to
treat sexual dysfunction of organic origin, including
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impotence and decreased libido. This exclusion
does not apply to sexual dysfunction diagnoses
listed in the current Diagnosis and Statistical
Manual (DSM).
EMERGENCY ROOM
This Plan covers Services You get in a Hospital
emergency room for an Emergency Medical
Condition. An Emergency Medical Condition could be
a heart attack, stroke, serious burn, chest pain,
severe pain or bleeding that does not stop. If You
are having a medical emergency You should call
911 or the emergency assistance number for Your
local area. You can go to the nearest Hospital
emergency room that can take care of You. If it is
possible, call Your Physician first and follow their
instructions.
 Weight management drugs or drugs for the
treatment of obesity
 Therapeutic devices or appliances. See Home
Medical Equipment (HME), Supplies, Devices,
Prosthetics and Orthotics
 Off Label oral chemotherapy Prescription Drugs.
See Chemotherapy and Radiation Therapy.
OUTPATIENT SURGERY SERVICES
You do not need Prior Authorization for emergency
room Services. You must let Us know if You are
admitted as an Inpatient from the emergency room,
as soon as reasonably possible. See the Prior
Authorization and Emergency Admission Notification
section for details.
This Plan covers Outpatient surgical Services at a
Hospital or Ambulatory Surgical Facility, surgical suite
or provider’s office. Some Outpatient surgeries must
be prior authorized before You have them. See the
Prior Authorization and Emergency Admission
Notification section for details.
Covered Services include the following:
Covered Services include:
 The emergency room
 Anesthesia and postoperative care
 Emergency room Physician, as shown on the
Summary of Your Costs
 Cornea transplants and skin grafts
 Cochlear implants, including bilateral implants
 Services used for Emergency Medical Screening
Exams and for stabilizing an Emergency Medical
Condition
 Blood transfusion, including blood derivatives
 Biopsies and scope insertion procedures such as
endoscopies
 Outpatient diagnostic tests billed by the emergency
room, that You get with other emergency room
Services
 Colonoscopy and sigmoidoscopy for a medical
condition
 Hospital based Urgent Care facilities
 Voluntary termination of pregnancy
Emergency Services benefits are covered at the innetwork cost share, up to the allowed amount from
any Hospital emergency room or other provider. You
pay any amounts over the allowed amount when You
get Services from out-of-network Physicians and
other providers, even if the Hospital emergency room
is in Our network.
 Vasectomy
 Reconstructive Surgery that is needed because of
an injury, infection or other Illness
Services of an assistant surgeon are covered only
when Medically Necessary. Benefits for an assistant
surgeon will not be more than 20% of the primary
surgeon’s allowed amount.
This benefit does not cover the inappropriate (nonemergency) use of an emergency room. This means
Services that could be delayed until You can be seen
in Your Physician’s office. This could be for things
like minor Illnesses such as cold, check-ups, follow-up
visits and Prescription Drug requests.
Sometimes more than one procedure is done during
the same surgery. These may be two separate
procedures or the same procedure on both sides of
the body. In these cases, benefits are based on the
allowed amount for the primary or main procedure
and half of the allowed amount for secondary
procedures.
EMERGENCY AMBULANCE SERVICES
This Plan covers emergency ambulance Services to
the nearest facility that can treat Your condition. The
medical care You get during the trip is also covered.
These Services are covered only when any other type
of transport would put Your health or safety at risk.
Covered Services also include transport from one
medical facility to another as needed for Your
condition.
This benefit does not cover:
 Routine colonoscopy, sigmoidoscopy and barium
enema screening. See the Preventive Care section
for details.
 Breast reconstruction. See Mastectomy and Breast
Reconstruction for those Covered Services.
 Transplant Services. See Transplant for details.
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This Plan covers emergency ambulance Services
from licensed providers only and only for the Member
who needs transport. Payment for Covered Services
will be paid directly to the ambulance provider.
done with other Hospital Services
Anesthesia for Dental Services
In some cases, this Plan covers anesthesia Services
for dental procedures. Covered Services include
general anesthesia and fees paid to the
anesthesiologist. Also covered are the related facility
charges (Inpatient or Outpatient) for a Hospital or
Ambulatory Surgical Facility or center. These
Services are covered only when they are Medically
Necessary and for one of the following reasons:
Prior Authorization is required for non-emergency
ambulance Services. See the Prior Authorization and
Emergency Admission Notification section for details.
URGENT CARE CENTERS
This Plan covers care You get in an Urgent Care
center. Urgent Care centers have extended hours
and are open to the public. You can go to an Urgent
Care center for an Illness or injury that needs
treatment right away. Examples are minor sprains,
cuts and ear, nose and throat infections. Covered
Services include the Physician's Services.
 The Member is under age 7 or has a disability and
it would not be safe and effective for the treatment
to take place in a dental office
 You have a medical condition (besides the dental
condition) that makes it unsafe to do the dental
treatment outside a Hospital or ambulatory surgical
center
You may have to pay a separate Copay or
Coinsurance for other Services You get during a visit.
This includes things such as x-rays, lab work,
therapeutic injections and office surgeries. See those
Covered Services for details.
This benefit does not cover:
 Hospital stays that are only for testing, unless the
tests cannot be done without Inpatient Hospital
facilities, or Your condition makes Inpatient care
Medically Necessary
Services You get in an Urgent Care center that are
billed by the Hospital or emergency room are covered
under the Emergency Services benefits.
 Any days of Inpatient care beyond what is
Medically Necessary to treat the condition
HOSPITAL SERVICES
 Dental treatment or procedures
This Plan covers Services You get in a Hospital. At
an in-network Hospital, You may get Services from
doctors or other providers who are not in Our network.
When You get covered Services from out-of-network
providers, You will pay any amount over the allowed
amount.
MENTAL HEALTH, BEHAVIORAL HEALTH
AND SUBSTANCE ABUSE
This Plan covers mental health care and treatment for
alcohol and drug dependence. This Plan will only
cover alcohol and drug Services from a stateapproved treatment program. You must also get
these Services in the lowest cost type of setting that
can give You the care You need. This Plan complies
with federal mental health parity requirements.
Inpatient Care
Covered Services include:
 Room and board, general duty nursing and special
diets
You must get Prior Authorization from Us before You
get treatment. See the Prior Authorization and
Emergency Admission Notification section for details.
 Doctor Services and visits
 Use of an intensive care or special care units
 Operating rooms, surgical supplies, anesthesia,
drugs, blood, dressing, equipment and oxygen
Outpatient Care
Medically Necessary reconstructive surgery services
due to a Mental Health condition, listed in the current
Diagnostic and Statistical Manual (DSM), are Covered
Services under the Outpatient Surgery Services
benefit or Hospital Services section for inpatient care.
Covered Services include:
Mental Health (Behavioral Health) Care
 X-ray, lab and testing
 Operating rooms, procedure rooms and recovery
rooms
This Plan covers all of the following Services:
 Inpatient, residential treatment and Outpatient care
to manage or reduce the effects of the Mental
Condition. Benefits include physical and
occupational therapy provided for treatment of a
mental condition, including autism spectrum
disorders and Pervasive Developmental Disorder
(PDD).
 Doctor Services
 Anesthesia
 Services, medical supplies and drugs that the
Hospital provides for Your use in the Hospital
 Lab and testing Services billed by the Hospital and
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 Individual, family or group therapy
This Plan covers all of the following Services:
 Lab and testing
 Direct treatment or direct therapy Services for
identified patients and/or family members when
provided by a licensed provider, BCBA or therapy
assistants who are supervised by a licensed
provider or BCBA
 Take-home drugs You get in a facility
In this benefit, “Outpatient visit” means a clinical
treatment session with a mental health provider.
 Initial evaluation/assessment when performed by a
licensed provider or BCBA
Alcohol and Drug Dependence (Substance Abuse)
This Plan covers all of the following Services:
 Treatment review and planning when performed by
a licensed provider or BCBA
 Inpatient and residential treatment and Outpatient
care to manage or reduce the effects of alcohol or
drug dependence, including screening and
treatment after a conviction of driving under the
influence of intoxicants
 Supervision of therapy assistants when performed
by a licensed provider or BCBA
 Communication/coordination with other providers or
school personnel when performed by a licensed
provider or BCBA
 Individual, family or group therapy
 Lab and testing
Delivery of ABA covered Services for an individual
may be managed by a BCBA or licensed provider
who is called a “program manager.”
 Take-home drugs You get in a facility
Applied Behavioral Analysis (ABA) Therapy
This Plan covers ABA therapy. The Member must be
diagnosed with one of the following disorders:
This benefit does not cover:
 Prescription Drugs. These are covered under
Prescription Drug benefit.
 Autistic disorder
 Autism spectrum disorder
 Treatment of sexual dysfunctions, such as
impotence dysfunctions of organic origin, including
impotence and decreased libido. This exclusion
does not apply to sexual dysfunction diagnoses
listed in the current Diagnostic and Statistical
Manual (DSM).
 Asperger’s disorder
 Childhood disintegrative disorder
 Pervasive Development Disorder
 Rett’s disorder
 Institutional care, except that Services are covered
when provided for an Illness or injury treated in an
acute care Hospital
Services must be provided by:
 A Physician (MD or DO) who is a psychiatrist,
developmental pediatrician or pediatric neurologist
 Dementia
 A state-licensed psychiatric nurse practitioner (NP),
advanced nurse practitioner (ANP) or advanced
registered nurse practitioner (ARNP)
 Sleep disorders. See Diagnostic Lab, X-ray and
Imaging.
 A state-licensed masters-level mental health
clinician (such as, licensed clinical social worker,
licensed marriage and family counselor, licensed
mental health counselor)
 EEG biofeedback or neurofeedback
 A state-licensed occupational or speech therapist
when providing ABA therapy
 Therapeutic or group homes, foster homes, nursing
homes boarding homes or schools and child
welfare facilities
 Family and marriage counseling or therapy, except
when it is Medically Necessary to treat Your Mental
Condition
 A state-licensed psychologist
 Outward bound, wilderness, camping or tall ship
programs or activities
 Licensed Community Mental Health or Behavioral
Health agency that is also state certified for ABA
therapy
 Phone Services, unless they are done in a crisis or
when the Member cannot get out of bed for medical
reasons. See Telemedicine Services for phone
that use real time video or audio.
 Board-Certified Behavioral Analyst (BCBA),
licensed in states with behavioral analyst licensure,
otherwise certified by the Behavioral Analyst
Certification Board
 Mental health tests that are not used to assess a
covered mental condition or plan treatment. This
Plan does not cover tests to decide legal
competence or for school or job placement.
 Therapy assistants/behavioral technicians/
paraprofessionals; when Services are supervised
and billed by a licensed provider or BCBA
 Support groups, such as Al-Anon or Alcoholics
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 Prescription Drugs. These are covered under the
Prescription Drugs benefit
Anonymous
 Services that are not Medically Necessary
 Any other activity that is not considered to be a
behavioral assessment or intervention utilizing
applied behavior analysis techniques
 Sober living homes, such as halfway houses
 Addiction to foods
 Caffeine dependence
MATERNITY AND NEWBORN CARE
 Training of therapy assistants/behavioral
technicians/paraprofessionals (as distinct from
supervision)
Maternity
This Plan covers Physicians and facility charges for
prenatal care, delivery and postnatal care. The
hospital stay for the mother is not limited to less than
48 hours for a vaginal delivery or less than 96 hours
following a cesarean section. A length of stay that will
be longer than these limits must be prior authorized.
See the Prior Authorization and Emergency
Admission Notification section for details.
 Accompanying the Member/identified patient to
appointments or activities outside of the home
(such as, recreational activities, eating out,
shopping, play activities, medical appointments),
except when the Member/identified patient has
demonstrated a pattern of significant behavioral
difficulties during specific activities
 Transporting the Member/identified patient in lieu of
parental/other family member transport
Home birth Services are also covered. The Services
must be provided by a licensed women’s health care
provider who is working within their license and scope
of practice.
 Assisting the Member with academic work or
functioning as a tutor, except when the Member
has demonstrated a pattern of significant
behavioral difficulties during school work
Newborn Care
This Plan covers newborn hospital nursery care and
includes pediatrician Services. Benefits for the
newborn Services are subject to the newborn’s
deductible and Coinsurance. The Hospital stay for
the newborn is not limited to less than 48 hours for a
vaginal delivery or less than 96 hours following a
cesarean section. A length of stay that will be longer
than these limits must be Prior Authorized. See the
Prior Authorization and Emergency Admission
Notification section for details.
 Functioning as an educational or other aide for the
Member/identified patient in school
 Provision of Services that are part of an Individual
Education Program (IEP) and therefore should be
provided by school personnel, or other services
that schools are obligated to provide
 Provider doing house work or chores, or assisting
the Member/identified patient with house work or
chores, except when the Member has
demonstrated a pattern of significant behavioral
difficulties during specific house work or chores, or
acquiring the skills to do specific house work or
chores is part of the ABA treatment plan for the
Member/identified patient
This benefit does not cover:
 Complications of Pregnancy. Complications of
pregnancy are covered as other medical services
and benefits are based on the type of Services You
get. For example, office visits are covered as
shown under Office and Clinic Visits; treatment for
diabetes is covered as described under Preventive
Care. See the Definitions section for a description
of Complications of Pregnancy.
 Provider travel time
 Babysitting
 Respite for parents or family members
 Provider residing in the Member’s home and
functioning as live-in help (such as. in an au-pair
role)
 Outpatient x-ray, lab and imaging. These Services
are covered under Diagnostic Lab, X-ray and
Imaging.
 Peer-mediated groups or interventions
 Training or classes for groups of parents of
different patients
 Home birth Services provided by family Members
or volunteers
 Hippotherapy or equestrian therapy
HOME HEALTH CARE
 Pet therapy
Home health care Services must be part of a home
health care plan. These Services are covered when a
qualified provider certifies that the Services are
provided or coordinated by a state-licensed or
Medicare-certified Home Health Agency or certified
rehabilitation agency.
 Auditory Integration Therapy (as part of ABA
Therapy)
 Sensory Integration Therapy (as part of ABA
Therapy)
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Covered Services include:
maintenance of a safe and healthy environment
and general support to the goals of the plan of care
 Home visits and acute nursing (short-term nursing
care for Illness or injury) by a home health agency
 Rehabilitation therapies provided for purposes of
symptom control or to enable You to maintain
activities of daily living and basic functional skills
 Therapeutic Services such as respiratory therapy
and phototherapy provided by the home health
agency
 Prescription Drugs and insulin provided by and
billed by a home health care provider or home
health agency
 Continuous home care during a period of crisis in
which You require skilled intervention to achieve
palliation or management of acute medical
symptoms
This benefit does not cover:
This benefit does not cover:
 Over-the-counter drugs, solutions and nutritional
supplements
 Over-the-counter drugs, solutions and nutritional
supplements
 Services provided to someone other than the ill or
injured Member
 Services provided to someone other than the ill or
injured Member
 Services provided by family Members or volunteers
 Services provided by family Members or volunteers
 Services or providers not in the written plan of care
or not named as covered in this benefit
 Services or providers not in the written plan of care
or not named as covered in this benefit
 Custodial Care, except for hospice care Services
 Custodial Care
 Nonmedical Services, such as housekeeping,
dietary assistance or spiritual bereavement, legal or
financial counseling
 Non-medical Services, such as housekeeping
 Services that provide food, such as Meals on
Wheels or advice about food
 Services that provide food, such as Meals on
Wheels or advice about food
HOSPICE CARE
A hospice care program must be provided in a
hospice facility or in Your home by a hospice care
agency or program.
REHABILITATION THERAPY
This Plan covers rehabilitation therapy. Benefits must
be provided by a licensed physical therapist,
occupational therapist, speech language pathologist
or a licensed qualified provider. Services must be
prescribed in writing by Your provider. The
prescription must include site, type of therapy, how
long and how often You should get the treatment.
Medically necessary rehabilitation Services for a
mental health condition are not subject to the limits
shown on the Summary of Your Costs. See Mental
Health, Behavioral Health and Substance Abuse for
those Covered Services.
You must get Prior Authorization from Us before You
get Inpatient treatment. See the Prior Authorization
and Emergency Admission Notification section for
details.
Covered Services include:
 Nursing care provided by or under the supervision
of a registered nurse
 Medical social Services provided by a medical
social worker who is working under the direction of
a Physician; this may include counseling for the
purpose of helping You and Your caregivers to
adjust to the approaching death
Rehabilitative therapy is therapy that helps get a part
of the body back to normal health or function. It
includes therapy to restore or improve a function of
the body or mind that was lost because of an
Accidental Injury, Illness or surgery.
 Services provided by a qualified provider
associated with the hospice program
 Short term Inpatient care provided in a hospice
Inpatient unit or other designated hospice bed in a
Hospital or Skilled Nursing Facility; this care may
be for the purpose of occasional respite for Your
caregivers (not to exceed 5 days), or for pain
control and symptom management
You can get Inpatient care in a specialized
rehabilitative unit of a Hospital. If You are already an
Inpatient, this benefit will start when Your care
becomes mainly rehabilitative. You must get Prior
Authorization from Us before You get Inpatient
treatment. See the Prior Authorization and
Emergency Admission Notification section for details.
 Home Medical Equipment, medical supplies and
devices, including medications used primarily for
the relief of pain and control of symptoms related to
the terminal Illness
This Plan covers Inpatient rehabilitative therapy only
when it meets these conditions:
 You cannot get these Services in a less intensive
 Home health aide Services for personal care,
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 You cannot get these Services in a less intensive
setting
setting
 The care is part of a written plan of treatment
prescribed by a doctor
 The care is part of a written plan of treatment
prescribed by a doctor
Covered services include all of the following:
Covered services include all of the following:
 Physical, speech and occupational therapies
 Physical therapy
 Chronic pain care
 Speech therapy
 Massage therapy
 Occupational therapy
This benefit does not cover:
This benefit does not cover:
 Massage therapy without any other treatment
 Rolfing, polarity therapy, growth and cognitive
therapies
 Rolfing, polarity therapy, growth and cognitive
therapies
 Self-direction or seminar type treatment
 Self-direction or seminar type treatment
 Charges for day or overnight facilities for intensive
nutrition, exercise, education, relaxation and similar
service
 Charges for day or overnight facilities for intensive
nutrition, exercise, education, relaxation and similar
service
 Recreational, vocational or educational therapy
 Recreational, vocational or educational therapy
 Exercise or maintenance-level programs
 Exercise or maintenance-level programs
 Social or cultural therapy
 Social or cultural therapy
 Treatment that the ill, injured or impaired Member
does not actively take part in
 Treatment that the ill, injured or impaired Member
does not actively take part in
 Gym or swim therapy
 Gym or swim therapy
 Custodial Care
 Custodial Care
HABILITATION THERAPY
CARDIAC REHABILITATION
This Plan covers habilitation therapy, including
therapy. Benefits must be provided by a licensed
physical therapist, occupational therapist, speech
language pathologist or a licensed qualified provider.
Services must be prescribed in writing by Your
provider. The prescription must include site, type of
therapy, how long and how often You should get the
treatment. Medically necessary rehabilitation
Services for a mental health condition are not subject
to the limits shown on the Summary of Your Costs.
See Mental Health, Behavioral Health and Substance
Abuse for those Covered Services.
This Plan covers cardiac rehabilitation. Covered
Services include the following:
 Inpatient Services (Phase I)
 Short-term outpatient hospital Services (Phase II).
These include Medically Necessary Services
provided in connection with a cardiac rehabilitation
exercise program.
This benefit does not cover:
 Covered Services do not include long term
Outpatient (Phase III) Services
SKILLED NURSING FACILITY AND CARE
Habilitative therapy is therapy that helps a person
keep, learn or improve skills and functioning for daily
living that may not be developing normally. Examples
are therapy for a child who isn’t walking or talking at
the expected age.
This Plan covers Skilled Nursing Facility Services.
Covered Services include room and board for a semiprivate room, plus Services You get while confined in
a Medicare-approved Skilled Nursing Facility.
Sometimes a patient goes from acute nursing care to
skilled nursing care without leaving the Hospital.
When that happens, this benefit starts on the day that
the care becomes primarily skilled nursing care.
You can get Inpatient care in a specialized unit of a
Hospital. If You are already an Inpatient, this benefit
will start when Your care becomes mainly habilitative.
You must get Prior Authorization from Us before You
get Inpatient treatment. See the Prior Authorization
and Emergency Admission Notification section for
details.
Skilled nursing care is covered only during certain
stages of recovery. It must be a time when Inpatient
Hospital care is no longer Medically Necessary, but
care in a Skilled Nursing Facility is Medically
Necessary. Your doctor must actively supervise Your
care while You are in the Skilled Nursing Facility.
This Plan covers Inpatient habilitative therapy only
when it meets these conditions:
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 Cast, braces and supportive devices when used in
the treatment of medical or surgical conditions in
acute or convalescent stages or as immediate postsurgical care
You must get Prior Authorization from Us before You
get treatment. See the Prior Authorization and
Emergency Admission Notification section for details.
HOME MEDICAL EQUIPMENT (HME),
SUPPLIES, DEVICES, PROSTHETICS AND
ORTHOTICS
 Medical devices surgically implanted in a body
cavity to replace or aid the function of an internal
organ
Services must be prescribed by Your Physician. Not
all supplies, devices or HME are a Covered Service
and are subject to the terms and conditions as
described in this Benefit Booklet. Documentation
must be provided which includes, the prescription
stating the diagnosis, the reason the service is
required and an estimate of the duration of its need.
The limit stated on the Summary of Your Costs does
not apply to essential health benefits. Essential
health benefits are Services defined by the Secretary
of the U.S. Department of Health and Human
Services. For this benefit, this includes Services such
as prosthetic and Orthotic devices, oxygen and
oxygen supplies, diabetic supplies, wheelchairs and
treatment of inborn errors of metabolism.
 Medical foods that are Medically Necessary for
supplementation or dietary replacement for the
treatment of inborn errors of metabolism. Inborn
errors of metabolism, include disorders that involve
amino acid, carbohydrate and fat metabolism for
which medically standard methods of diagnosis,
treatment and monitoring exist, including
quantification metabolites in blood, urine or spinal
fluid, or enzyme or DNA confirmation in tissues.
Medical foods are foods that are formulated to be
consumed or administered enterally under strict
medical supervision for the treatment of inborn
errors of metabolism including, but not limited to:
phenylketomuria (PKU), homcystinuria,
citrullinemia, maple syrup disease and pyruvate
dehydorgenase deficiency.
Prior Authorization is required for some medical
supplies/devices, HME, prosthetics and Orthotics.
Please see the Prior Authorization and Emergency
Admission Notification section of this Benefit Booklet
for details.
Medical Vision Hardware
Benefits for medical vision hardware, including
eyeglasses, contact lenses and other corneal lenses
are covered when such devices are required for the
following medical conditions: corneal ulcer, bullous
keratopathy, recurrent erosion of cornea, tear film
insufficiency, aphakia, Sjogren’s disease, congenital
cataract, corneal abrasion and keratoconus.
Home Medical Equipment (HME)
This Plan covers rental of medical and respiratory
equipment (including fitting expenses), not to exceed
the purchase price, when Medically Necessary and
prescribed by a Physician for therapeutic use in direct
treatment of a covered Illness or injury. Benefits may
also be provided for the initial purchase of equipment,
in lieu of rental. In cases where an alternative type of
equipment is less costly and serves the same medical
purpose, We will provide benefits only up to the lesser
amount. Repair or replacement of medical or
respiratory equipment Medically Necessary due to
normal use or growth of a child is covered.
Prosthetics and Orthotic Devices
Benefits for external prosthetic devices (including
fitting expenses) are covered when such devices are
used to replace all or part of an absent body limb or to
replace all or part of the function of a permanently
inoperative or malfunctioning body organ.
Covered Services include the following:
 Prosthetic devices such as an artificial limb,
external breast prosthesis following mastectomy,
artificial eye
Medical and respiratory equipment includes, but is not
limited to, wheelchairs, hospital-type beds, traction
equipment, ventilators and diabetic equipment such
as blood glucose monitors, insulin pumps and
accessories to pumps and insulin infusion devices.
 Orthotic devices, supports or braces applied to an
existing portion of the body for weak or ineffective
joints or muscles
Medical Supplies
 Maxillofacial prosthetic devices that are required for
the restoration and management of head and facial
structures that cannot be replaced by living tissue,
are defective due to disease, trauma or
developmental deformity, to control or eliminate
infection and pain and restore facial configuration
and function
Medical supplies include, but are not limited to:
 Medically Necessary supplies as ordered by Your
Physician, including but not limited to, ostomy
supplies, non-prescription elemental enteral
formula for home use. Covered Services also
include only the following diabetic supplies: blood
glucose monitor, insulin pump (including
accessories).
Benefits will only be provided for the initial purchase
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of a prosthetic device, unless the existing device
cannot be repaired. Replacement devices must be
prescribed by a Physician because of a change in
Your physical condition.
OTHER COVERED SERVICES
The Services listed in this section are covered as
shown on the Summary of Your Costs. Please see
the summary for Your Copays, deductible,
Coinsurance and benefit limits.
Shoe Inserts and Orthopedic Shoes
Benefits are provided for one Medically Necessary
shoes, inserts or orthopedic shoes for the treatment of
diabetes, congenital defect or as a result of surgery.
Covered Services also include training and fitting.
ALLERGY TESTING AND TREATMENT
This Plan covers allergy tests and treatments.
Covered Services include testing, shots given at the
doctor’s office, serums, needles and syringes.
This benefit does not cover:
BIOFEEDBACK
 Hypodermic needles, lancets, test strips, testing
agents and alcohol swabs. These Services are
covered under the Prescription Drug benefit.
This Plan covers Outpatient biofeedback training for
an illness or injury.
 Supplies or equipment not primarily intended for
medical use
CHEMOTHERAPY AND RADIATION
THERAPY
 Special or extra-cost convenience features
This Plan covers Services for chemotherapy and
radiation therapy. Covered Services include the
following:
 Items such as exercise equipment and weights
 Whirlpools, whirlpool baths, portable whirlpool
pumps, sauna baths and massage devices
 Prescribed oral anti-cancer medications used to kill
or slow the growth of cancerous cells.
 Over bed tables, elevators, vision aids and
telephone alert systems
 Prescribed oral anti-cancer medications used for off
label use.
 Structural modifications to Your home and/or
personal vehicle
 Services performed or ordered by Your Physician.
This benefit applies to Services You get during an
office visit or at a facility.
 Orthopedic appliances prescribed primarily for use
during participation of a sport, recreation or similar
activity
You must get Prior Authorization from Us before You
get treatment. See the Prior Authorization and
Emergency Admission Notification section for details.
 Penile prostheses
 Routine eye care Services including eye glasses
and contact lenses
CLINICAL TRIALS
 Items which are replaced due to loss or negligence
This Plan covers the routine costs of a qualified
clinical trial. Routine costs mean Medically
Necessary care that is normally covered under this
Plan outside the clinical trial. Benefits are based on
the type of service You get. For example, benefits of
an office visit are covered under Office and Clinic
Visits, and lab tests are covered under Diagnostic
Lab, X-ray and Imaging.
 Items which are replaced due to the availability of a
newer or more efficient model, unless determined
otherwise
 Prosthetics, intraocular lenses, appliances or
devices requiring surgical implantation. These
items are covered under surgical benefits. Items
provided and billed by a Hospital are covered under
the Hospital benefit for Inpatient and Outpatient
care.
A qualified clinical trial is a trial that is funded and
supported by the National Institutes of Health, the
Center for Disease Control and Prevention, the
Agency for Healthcare Research and Quality, the
Centers for Medicare and Medicaid Services, the
United States Department of Defense or the United
States Department of Veterans Affairs.
 Over the counter orthotic braces and or cranial
banding
 Non wearable defibrillator, trusses and ultrasonic
nebulizers
 Blood pressure cuff/monitor (even if prescribed by
a physician)
We encourage You or Your provider to call Customer
Service before You enroll in a clinical trial. We can
help You verify that the clinical trial is a qualified
clinical trial. You may also be assigned a nurse case
manager to work with You and Your provider. See
Personal Health Support Programs section for details.
 Enuresis alarm
 Compression stockings which do not require a
prescription
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professional Services, facility charges, and any
supplies, drugs or solutions used for dialysis.
CRANIOFACIAL ANOMALIES
This Plan covers dental and orthodontic Services for
the treatment of craniofacial anomalies when the
Services are Medically Necessary to restore function
for a physical disorder, identifiable at birth that affect
the bony structures of the face and head. These
include but not limited to: cleft palate, cleft lip,
craniosynstosis, craniofacial microsomia and
Treacher Collins syndrome.
If You receive dialysis Services due to a diagnosis of
end stage renal disease, You may be eligible to enroll
in Medicare. If You enroll in Medicare, this Plan will
coordinate benefits per Medicare rules. Generally,
this Plan will be the primary payer for 30 months, and
Medicare will be the primary payer after 30 months.
For more information about Medicare enrollment,
contact Medicare at 1-800-MEDICARE or log onto
their web site at www.medicare.gov.
This benefit does not include coverage for
maxillofacial conditions that result in overbite,
crossbite, malocclusion or similar developmental
irregularities of the teeth or temporomandibular joint
disorder.
FOOT CARE
This Plan covers routine foot care for the treatment of
diabetes. Covered Services include treatment for
corns, calluses, toenail conditions other than infection
and hypertrophy or hyperplasia of the skin of the feet.
DENTAL ACCIDENTS
This plan covers accidental injuries to teeth, gums or
jaw. Covered Services include exams, consultations
and dental treatment. Services are covered when all
of the following are true:
INFUSION THERAPY (OUTPATIENT)
This Plan covers Outpatient infusion therapy
Services, supplies, solutions and drugs.
 Treatment is needed because of an Accidental
Injury
You must get Prior Authorization from Us before You
get treatment. See the Prior Authorization and
Emergency Admission Notification section for details.
 Treatment is done on the natural tooth structure
and the teeth were free from decay and functionally
sound when the injury happened. Functionally
sound means that the teeth do not have:
MASTECTOMY AND BREAST
RECONSTRUCTION
 Extensive restoration, veneers, crowns or splints
This Plan covers mastectomy needed because of
disease, Illness or Accidental Injury and breast
reconstruction. For any Member electing breast
reconstruction in connection with a mastectomy, this
benefit covers:
 Periodontal (gum) disease or any other condition
that would make them weak
This benefit does not cover:
 Damage from biting or chewing, even when caused
by a foreign object in food.
 Reconstruction of the breast on which mastectomy
has been performed including but not limited to
nipple reconstruction, skin grafts and stippling of
the nipple and areola
DENTAL ANESTHESIA
In certain cases, this Plan covers general anesthesia,
professional Services and facility charges for dental
procedures. These Services can be in a Hospital or
an ambulatory surgical facility. They are covered only
when Medically Necessary for one of these reasons:
 Surgery and reconstruction of the other breast to
produce a symmetrical appearance
 Prostheses
 Complications of all stages of mastectomy,
including lymphedemas.
 The Member is under age 7 years old, or has a
disability and it would not be safe and effective to
treat them in a dental office
 Inpatient care related to the mastectomy and postmastectomy Services
 You have a medical condition (besides the dental
condition) that makes it unsafe to do the dental
treatment outside a Hospital or ambulatory surgical
center
Services are provided in a manner determined by the
attending Physician with the patient in accordance
with state requirements and federal WHCRA 1998
requirements.
This benefit does not cover:
You must get Prior Authorization for Inpatient
admissions before You get treatment. You will only
need a single Prior Authorization for all Services
included in Your plan of treatment. See the Prior
Authorization and Emergency Admission Notification
section for details.
 The dental procedure
DIALYSIS SERVICES
This Plan covers dialysis Services You get in an office
visit or at a facility. Benefits are provided for
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ROUTINE VISION CARE
THERAPEUTIC INJECTIONS
Benefits for routine vision care are provided as shown
on the Summary of Your Costs.
This Plan covers therapeutic injections given at the
doctor's office, including serums, needles and
syringes.
Covered Services include the following:
Vision Exam
TRANSPLANTS
Covered Services include the vision analysis by an
Ophthalmologist or an Optometrist. A vision analysis
may consist of external and ophthalmoscopic
examination, determination of best corrected visual
acuity, determination of the refractive state, gross
visual fields, basic sensorimotor examination, and
glaucoma screening.
This Plan covers transplant Services when they are
provided at an approved transplant center. An
approved transplant center is a Hospital or other
provider that LifeWise has approved for solid organ
transplants or bone marrow or stem cell reinfusion.
Please call Us as soon as You learn You need a
transplant.
Corrective Vision Hardware
Covered Transplants
Covered Services include those provided by an
Optician or Optometrist when prescribed by an
Ophthalmologist or Optometrist. Corrective eyewear
benefits include:
This Plan covers only transplant procedures that are
not considered Experimental or Investigational for
Your condition. Solid organ transplants and bone
marrow/stem cell reinfusion procedures must meet
coverage criteria. We review the medical reasons for
the transplant, how effective the procedure is and
possible medical alternatives.
 Lenses
 Frames
 Contact Lenses
These are the types of transplants and reinfusion
procedures that meet Our criteria for coverage:
SLEEP STUDIES
 Heart
This Plan covers sleep studies when done at a
certified sleep laboratory. The Services must be
ordered by a pulmonologist, neurologist,
otolaryngologist or certified sleep medicine specialist.
 Heart/double lung
 Single lung
 Double lung
Please see the Prior Authorization and Emergency
Admission Notification section of this Benefit Booklet
for details.
 Liver
TELEHEALTH VIRTUAL CARE SERVICES
 Pancreas with kidney
 Kidney
 Pancreas
This Plan covers access to care via online and
telephonic methods as shown on the Summary of
Your Costs. Your Qualified Practitioner will determine
which conditions and circumstances are appropriate
for Telehealth Virtual Care Services.
 Bone marrow (autologous and allogeneic)
 Stem cell (autologous)
Under this benefit, transplant does not include cornea
transplant or skin grafts. It also does not include
transplants of blood or blood derivatives (except bone
marrow or stem cells). These procedures are
covered the same way as other covered surgical
procedures.
TELEMEDICAL SERVICES
This Plan covers telemedicine Services delivered
through two-way video communication. Covered
Services include consultations, office visits, individual
psychotherapy and pharmacologic management for
telecommunication between a provider and a
Member.
Recipient Costs
Benefits are provided for Services from an approved
transplant center and related professional Services.
This benefit also provides coverage for anti-rejection
drugs given by the transplant center.
This Plan also covers Telemedicine Services for
diabetes as required by state law.
Covered Services consist of all phases of treatment:
This benefit does not cover:
 Evaluation
 Get acquainted visits without physical exam or
diagnosis or therapeutic intervention
 Pre-transplant care
 Transplant and any donor Covered Services
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 Follow-up treatment
this Plan. In addition to the Services listed as not
covered under the Covered Services section, all of
the following are excluded from coverage under this
Plan:
Donor Costs
This benefit covers donor or procurement expenses
for a covered transplant. Covered Services include:
Amounts Over the Allowed Amount
 Selection, removal (harvesting) and evaluation of
the donor organ, bone marrow or stem cell
This Plan does not cover amounts over the allowed
amount as defined in this Plan. You will have to pay
charges over the allowed amount.
 Transportation of the donor organ, bone marrow or
stem cells, including the surgical and harvesting
teams
Bariatric Surgery
 Donor acquisition costs such as testing and typing
expenses
This Plan does not cover Services for bariatric
surgery and any resulting complications, including,
but not limited to Laparoscopic Gastric Bypass,
Laparoscopic Mini-gastric Bypass, Biliopancreatic
Bypass, Fobi Pouch, Vertical Banded Gastroplasty,
Laparoscopic Adjustable Gastric Banding except to
the extent as outlined under Emergency Care
Services provision in the How To Obtain Services
section of the contract.
 Storage costs for bone marrow and stem cells for
up to 12 months
Transportation and Lodging
This benefit covers costs for transportation and
lodging for the Member getting the transplant (while
not confined) and one companion, not to exceed three
(3) months. The Member getting the transplant must
live more than 50 miles from the facility, unless
treatment protocols require them to remain closer to
the transplant center.
Benefits from Other Sources
This Plan does not cover Services that are covered
by:
 A motor vehicle insurance contract, as required by
Oregon state mandated minimum personal injury
protection (PIP) coverage
EMPLOYEE WELLNESS
Employees of the Group who are enrolled as of the
renewal / effective date, are eligible to earn a $100
award by completing the following activities within the
first 90-days of the Plan Year:
Biometric Screening. This screening can provide
information about blood pressure, glucose,
cholesterol and body mass. Knowing these
numbers helps you understand your health risks
and make changes to improve your health. Have
your healthcare provider fill out the Biometric
Screening Form and return it to us at the address
or fax number listed on the form. The form asks for
information about blood pressure, glucose,
cholesterol and body mass. You can get the form
from our website lifewise.com.
Health Risk Assessment. This is a selfassessment tool that includes questions about
health habits. You can take this assessment on Our
website at lifewiseor.com. Or, if You do not have
access to a computer, please call Customer
Service at the phone number located on the inside
front cover of this Benefit Booklet.
 A Motor vehicle insurance contract or insurance
offering Underinsured Motorists or Uninsured
Motorists (UIM) coverage
 A commercial and/or a homeowner’s medical
premises coverage, or other similar type of
insurance or contract
 Other type of liability or insurance coverage
 Services and supplies provided or payable under
any Plan or law through a Government or any
political subdivision, unless prohibited by law
 Worker’s Compensation or similar coverage
Benefits That Have Been Used Up
This Plan does not cover Services over a stated
benefit maximum limit.
Biofeedback
This Plan does not cover biofeedback in excess of the
benefits as described in the Covered Services
section.
The award is only available to employees of the
Group.
Comfort or Convenience
In some cases a health coach may contact You and
ask if they can help You improve Your health.
 Items that are mainly for Your convenience or that
of Your family. For instance, this Plan does not
cover personal services or items like meals for
guests, long-distance phone, radio or TV and
personal grooming.
This Plan does not cover:
EXCLUSIONS
This section lists the Services that are not covered by
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 Normal living needs, such as food, clothes,
housekeeping and transport. This does not apply
to chores done by a home health aide as
prescribed in Your treatment plan.
 Your Spouse, mother, father, child, brother or sister
 Your mother, father, child, brother or sister by
marriage
 Your stepmother, stepfather, stepchild, stepbrother
or stepsister
 Help with meals, diets and nutrition. This includes
Meals on Wheels.
Community Wellness Services
 Your grandmother, grandfather, grandchild or the
Spouse of one of these people
Community wellness classes or programs
 A volunteer, except as described in Home Health
and Hospice Care
Cosmetic Services
Food Supplements
This Plan does not cover Services and supplies for
Cosmetic Services, including but not limited to:
This Plan does not cover food supplements, herbal,
naturopathic or homeopathic medicine remedies or
devices, dietaries and any other non-prescription
supplements whether or not prescribed or
recommended by Your provider.
 Services performed to reshape normal structures of
the body in order to improve or alter Your
appearance and self-esteem and not primarily to
restore an impaired function of the body
Get Acquainted Visits
Reconstructive surgery resulting from an Accidental
Injury, infection or other illness may be a Covered
Service. Reconstructive breast surgery resulting from
a mastectomy or lumpectomy as a result of treatment
of cancer is a Covered Service. Please see the
Outpatient Surgery Services and Mastectomy and
Breast Reconstruction headings for these Covered
Services in the Covered Services section. Please see
Mental Health, Behavioral Health and Substance
Abuse headings for these Covered Services in the
Covered Services section.
This Plan does not cover get acquainted visits without
physical assessment or diagnostic or therapeutic
Services.
Hair Prosthesis
This Plan does not cover hair loss, hair prosthesis,
hair transplant or implants, wigs and drugs.
Health Clubs or Health Spas
This Plan does not cover health clubs or health spas,
YMCA or similar facilities, aerobic and strength
conditioning, exercise or non-specific physical
conditioning programs, massage therapy, workhardening programs and all related material and
products for these programs.
Counseling and Training
This Plan does not cover counseling or training, job
help and outreach and social or fitness counseling.
Court-Ordered Services
Court ordered Services, unless You are receiving
treatment due to a conviction while driving under the
influence of intoxicants. Services must be Medically
Necessary.
Hearing Exams
Custodial Care
Human Growth Hormone
Donor Breast Milk
This Plan does not cover:
Environmental Therapy
 Medications, drugs and hormones to stimulate
growth except when determined to meet medical
criteria and as described in the Prescription Drugs
section in the Covered Services section.
This Plan does not cover routine hearing care,
including hearing examinations and diagnostic
screening
This Plan does not cover therapy to provide a
changed or controlled environment.
Experimental or Investigational
 Drugs or hormones to stimulate growth for
idiopathic short stature without growth hormone
deficiency
This Plan does not cover any service that is
Experimental or Investigational, see Definitions
section. This Plan also does not cover any
complications or effects of such Services.
Illegal Acts and Terrorism
This Plan does not cover Illness or injuries resulting
from any of the following events occurring while the
Member is covered under this Plan, unless required
by law:
Family Members or Volunteers
This Plan does not cover charges for Services that
You do Yourself. It also does not cover a provider
who is:
 A felony
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 An act of terrorism
Orthognathic and Maxillofacial Surgery
 An act of riot or revolt
This Plan does not cover procedures to make the jaw
longer or shorter, except when determined to meet
required medical criteria and as required by law.
Infertility and Assisted Reproduction
This Plan does not cover:
Preventive Care
 Services for infertility or fertility problems
This Plan does not cover preventive care in excess of
the preventive care benefits, including Services that
exceed the frequency, age and gender guidelines set
by the United States Preventive Services Task Force
(USPSTF), Centers for Disease Control and
Prevention (CDC), and Health Resources and
Services Administration (HRSA) and as shown on the
Summary of Your Costs.
 Assisted reproduction methods, such as artificial
insemination or in-vitro fertilization
 Services to make You more fertile or for multiple
births
 Undoing of sterilization surgery
 Complications of these Services
Light or Laser Therapy for Vitiligo
Private Duty Nursing
Low Level Laser Therapy
This Plan does not cover private duty or 24-hour
nursing care. See the Home Health Care benefit for
home nursing care benefits.
Military Service and War
This Plan does not cover Illness or injuries that are
caused by or arises from any of the following events
occurring while the Member is covered under this
Plan, unless required by law:
Serious Adverse Events and Never Events
This Plan does not cover serious adverse events and
never events. These are serious medical errors that
the U.S. government has identified and published. A
serious adverse event is an injury that is caused by
treatment in the Hospital and not by a disease. Such
events make the hospital stay longer or cause
another health problem. A never event should never
happen in a Hospital. A never event is when the
wrong surgery is done, or a procedure is done on the
wrong person or body part.
 Acts of war, such as armed invasion, no matter if
war has been declared or not
 Services in the armed forces of any country. This
includes the air force, army, coast guard, marines,
National Guard or navy. It also includes any
related civilian forces or units.
No Charge or You Do Not Legally Have to Pay
This Plan does not cover Services for which no
charge is made. This is also true if no charge would
have been made if this Plan were not in effect. The
Plan also does not cover Services that You do not
legally have to pay, except as required by law.
You do not have to pay for Services of in-network
providers for these events and their follow-up care.
In-network providers may not bill You or this Plan for
these Services.
Not all medical errors are serious adverse events or
never events. These events are very rare. You can
ask Us for more details. You can also get more
details from the U.S. government. You will find them
at www.cms.hhs.gov.
Non-Medical Detoxification
Detoxification Services that do not consist of active
medical management. See Definitions section.
Non-Treatment Facilitated, Institutions or
Programs
Services Not Furnished by a Hospital, Licensed
Provider or Licensed Treatment Facility
Benefits are not provided for institutional care,
housing, incarceration or programs from facilities that
are not licensed to provide medical or behavioral
health treatment for covered conditions. Examples
are prisons, nursing homes and juvenile detention
facilities. Benefits are provided for Medically
Necessary medical or behavioral health treatment
received in these locations.
This Plan does not cover Services that are not
furnished by a Hospital, provider or treatment facility,
or that are outside the scope of a provider’s license or
certification, or that are furnished by a provider that is
not licensed or certified by the jurisdiction in which the
Services were received. This includes unlicensed
practitioners or Physicians, homeopaths, massage
therapists, faith healers and midwives.
Not Medically Necessary
Services of an Institution for the Developmentally
Disabled
This Plan does not cover Services that are not
Medically Necessary. This rule also applies to the
place where You get the Services.
This Plan does not cover Services of an institution for
the developmentally disabled, except while in an
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acute care Hospital for an Accidental Injury or Illness.
Weight Loss Surgery or Drugs
Services Provided for Lodging Accommodations
and Transportation
This Plan does not cover surgery, drugs or
supplements for weight loss or weight control. It also
does not cover any complications, follow-up Services,
or effects of those treatments, except as outlined
under Emergency Care. This is true even if You have
an Illness or injury that might be helped by weight
loss. This Plan does not cover removal of excess
skin and or fat that came about as a result of weight
loss surgery or the use of weight loss drugs.
This Plan does not cover lodging accommodations,
transportation and travel time except as described
under the Transplant benefit in the Covered Services
section.
Services that are Not a Covered Service
This Plan does not cover Services that are not a
Covered Service, including Hospital, ancillary or other
Services performed in association with a service that
is not a Covered Service, Services provided for
complications resulting from a non-Covered Service
and Services not provided, except as provided in the
emergency room for stabilization.
OTHER COVERAGE
COORDINATION OF BENEFITS
The Coordination of Benefits (COB) with other Plans
provision applies when a Member has more than one
health Plan.
Sexual Problems
Certain rules determine which health Plan will pay
first, this is called the primary Plan; the Plan that pays
after the primary Plan is called the secondary Plan.
The primary Plan must pay benefits in accordance
with its policy terms and limitations as if You have no
other coverage. The secondary Plan may reduce the
benefits it pays so that the payments from all Plans do
not exceed 100% of the total allowable expense.
This Plan does not cover treatment of sexual
functions of organic origin, including impotence and
decreased libido. This exclusion does not apply to
sexual dysfunction diagnoses listed in the current
Diagnostic and Statistical Manual (DSM).
Temporomandibular Joint (TMJ) Disorders
This Plan does not cover treatment of TMJ disorders.
TMJ disorders are problems with the lower jaw joint
that have one or more of the features below:
A health savings account may be affected by
enrollment in more than one Health Benefit Plan.
Employees using this Plan in conjunction with a
health savings account should check with their tax
advisors regarding federal tax obligations and
requirements as a result of having more than one
Health Benefit Plan.
 Pain in the muscles near the TMJ
 Internal derangements of the parts of the TMJ
 Arthritic problems with the TMJ
 The TMJ has a limited range of motion or its range
of motion is not normal
DEFINITIONS
For the purposes of COB:
Vision Care
 A Plan is any of the following that provides benefits
or Services for medical or dental care. If separate
contracts are used to provide coordinated coverage
for group Members, all the contracts are
considered parts of the same Plan and there is no
COB among them. However, if COB rules do not
apply to all contracts, or to all benefits in the same
contract, the contract or benefit to which COB does
not apply is treated as a separate Plan.
This Plan does not cover Services in excess of the
vision benefit as described in the Covered Services
section and as shown on the Summary of Your Costs,
including:
 Orthoptics, pleoptics, visual analysis therapy and/or
training
 Surgeries or other procedures performed to
improve or change the refractive character of the
cornea, including any direct or indirect
complications thereof
 "Plan" includes: individual insurance contracts
and subscriber contracts, individual closed panel
plans, group insurance contracts, health
maintenance organization (HMO) contracts,
closed panel plans or other forms of group or
group-type coverage (whether insured or
uninsured); medical care components of group
long-term care contracts, such as skilled nursing
care; and Medicare or any other federal
governmental plan, as permitted by law. Group
and individual insurance contracts and
Please see Medical Supplies/Devices and Prosthetic
Devices under Covered Services section for covered
medical supplies related to cataract removal and
corneal transplant surgery.
Voluntary Support Groups
Patient support, consumer or affinity groups such as
diabetic support groups or Alcoholics Anonymous.
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subscriber contracts that pay or reimburse for the
cost of dental care.
been contracted with or employed by the Plan, and
excludes coverage for Services provided by other
providers, except in cases of emergency or referral
by a panel Member.
 "Plan" does not include: hospital indemnity
coverage or other fixed indemnity coverage;
accident only coverage; specified disease or
accident coverage; school accident type
coverage; benefits for non-medical components
of group long-term care policies; Medicare
supplement policies; Medicaid policies; or
coverage under other federal governmental
Plans, unless permitted by law.
 Custodial parent is the parent awarded custody by
a court decree or, in the absence of a court decree,
is the parent with whom the child resides more than
half of the Calendar Year, excluding any temporary
visitation.
 This Plan means the part of the contract providing
health care benefits to which the COB provision
applies and which may be reduced because of the
benefits of other Plans. Any other part of the
contract providing health care benefits is separate
from this Plan. A contract may apply one COB
provision to certain benefits, such as dental
benefits, coordinating only with similar benefits, and
may apply another COB provision to coordinate
other benefits. Dental benefits are coordinated
only with other Plans' dental benefits, while medical
benefits are coordinated only with other Plans'
medical benefits.
When a Member is covered by two or more Plans, the
rules for determining the order of benefit payments
are listed below. A Plan that does not include a COB
provision that complies with Oregon state COB
regulations is always primary unless the provisions of
both Plans make the complying Plan primary. The
exception is group coverage that supplements a
package of benefits provided by the same group.
Such coverage can be excess to the rest of that
group's Plan. An example is coverage paired with a
closed panel Plan to provide out-of-network benefits.
ORDER OF BENEFIT DETERMINATION
RULES
The first of the rules below determine which Plan is
primary. If You have more than one secondary Plan,
the rules below also determine the order of the
secondary Plans to each other.
 Primary Plan is a Plan that provides benefits as if
You had no other coverage.
 Secondary Plan is a Plan that is allowed to reduce
its benefits in accordance with COB rules.
Non-Dependent or Dependent The Plan that does
not cover You as a Dependent, is primary to a Plan
that does. However, if You have Medicare, and
federal law makes Medicare secondary to Your
Dependent coverage and primary to the Plan that
does not cover You as a Dependent, then the order is
reversed.
 Allowable expense is a health care expense,
including deductibles, Coinsurance and Copays,
that is covered at least in part by any of Your Plans.
When a Plan provides benefits in the form of
Services, the reasonable cash value of each
service is an allowable expense and a benefit paid.
An amount that is not covered by any of Your Plans
is not an allowable expense.
Below are some expenses that are not allowable
expenses:
Dependent children Unless a court decree states
otherwise, the rules below apply:
 Birthday rule When the parents are married or
living together, whether or not they were ever
married, the Plan of the parent whose birthday
(month/day) falls earlier in the Calendar Year is
primary. If both parents have the same birthday,
the Plan that has covered the parent the longest is
primary.
 The cost difference between a semi-private and
a private hospital room, unless one of the Plans
covers private rooms.
 Any amount over the highest of the expense
amounts allowed by either the primary Plan or
the secondary Plan. This is true regardless of
what method the Plans use to set the allowable
expenses. However, when Medicare is primary
to Your other coverage, Medicare's allowable
expense must be treated as the highest
allowable.
 When the parents are divorced, separated or not
living together, whether or not they were ever
married:
 If a court decree makes one parent responsible
for the child's health care expenses or coverage,
that Plan is primary. This rule applies to
Calendar Years starting after the Plan is given
notice of the court decree.
 Amounts reduced by the primary Plan because
You did not comply with its Plan provisions.
 Closed panel Plan is a Plan that provides health
care benefits to Members primarily in the form of
Services through a panel of providers that has
 If a court decree assigns one parent primary
financial responsibility for the child but doesn't
mention responsibility for health care expenses,
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the Plan of the parent with financial responsibility
is primary.
Plan only when it is secondary to that Plan. The
secondary Plan is allowed to reduce its benefits so
that the total benefits provided by all Plans are not
more than the total allowable expenses for that Claim.
For each Claim, the benefits of the primary and
secondary Plans must total 100% of the highest
allowable expense allowed for the service or supply
by either Plan. However, the secondary Plan is
never required to pay more than its benefits in the
absence of COB.
 If a court decree makes both parents responsible
for the child's health care expenses or coverage,
the birthday rule determines which Plan is
primary.
 If a court decree states that the parents have
joint custody without specifying that one parent
has responsibility for the health care expenses or
health care coverage of the Dependent child, the
birthday rule determines which Plan is primary.
The secondary Plan must credit to its deductible any
amounts it would have credited if it had been primary.
If there is no court decree allocating responsibility for
the child's expenses or coverage, the rules below
apply:
RIGHT TO RECEIVE AND RELEASE NEEDED
INFORMATION
 The Plan covering the custodial parent, first;
Certain facts about Your other health care coverage
are needed to apply the COB rules. We may get the
facts We need for COB from, or give them to, other
Plans, organizations or persons. We don't need to tell
or get the consent of anyone to do this. State
regulations require each of Your other Plans and each
person claiming benefits under this Plan to give Us
any facts We need for COB.
 The Plan covering the Spouse of the custodial
parent, second;
 The Plan covering the non-custodial parent, third;
and then
 The Plan covering the Spouse of the non-custodial
parent, last.
 If a child is covered by individuals other than
parents or stepparents, the above rules apply as if
those individuals were the parents.
RIGHT OF RECOVERY / FACILITY OF
PAYMENT
If Your other Plan makes payments that this Plan
should have made, We have the right, at Our
discretion, to remit to the other Plan the amount We
determine is needed to comply with COB. To the
extent of such payment, We are fully discharged from
liability under this Plan. We also have the right to
recover any payment over the maximum amount
required under COB. We can recover excess
payment from anyone to whom or for whom the
payment was made or from any other issuers or
Plans.
Retired or laid-off employee The Plan that covers
You as an active employee (an employee who is
neither laid-off nor retired) is primary to a Plan
covering You as a retired or laid-off employee. The
same is true if You are covered as both a Dependent
of an active employee and a Dependent of a retired or
laid-off employee.
Continuation coverage If You have coverage under
COBRA or other continuation law, that coverage is
secondary to coverage that is not through COBRA or
other continuation law.
This Plan has the right to appoint a third party to act
on its behalf in recovery efforts.
The retiree/layoff and continuation rules do not apply
when both Plans don't have the rule or when the
"non-Dependent or Dependent" rule can decide which
of the Plans is primary.
NON–DUPLICATION OF COVERAGE
Coordination with Medicare
Length of coverage The Plan that covered You
longer is primary to the Plan that didn't cover You as
long.
In all cases, coordination of benefits with Medicare
will conform to federal statutes and regulations.
Medicare means Title XVIII, Parts A and B Social
Security Act, as enacted or amended. Medicare
eligibility and how We determine Our benefit limits are
affected by disability and employment status. Please
contact Customer Service at the number listed in the
front of Your Benefit Booklet for additional
information.
If none of the rules above apply, the Plans must share
the allowable expenses equally. This Plan will not
pay more that it would have paid had it been the
primary Plan.
EFFECT ON THE BENEFITS OF THIS PLAN
The primary Plan provides its benefits as if You had
no other coverage.
NOTICE TO COVERED PERSONS
If You are covered by more than one Health Benefit
Plan, You should file all Your Claims with each Plan.
A Plan may take into account the benefits of another
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liability/subrogation can discuss with You what Our
procedures are and what You need to do.
THIRD PARTY LIABILITY
The following provisions will apply when You have
received Services for a condition for which one or
more third parties may be responsible. “Third party”
means any person other than you, (the first party to
this policy) and LifeWise (the second party), and
includes any insurance carrier providing liability or
other coverage potentially available to you. For
example, uninsured or underinsured motorist
coverage, whether under Your policy or not, is subject
to recovery by Us as a third-party recovery. Failure
by You to comply with the terms of this section will be
a basis for LifeWise to deny any Claims for benefits
arising from the condition. In addition, You must
execute and deliver to Us or other parties any
document requested by Us which may be appropriate
to secure the rights and obligations of You and
LifeWise under these provisions.
Proceeds of Settlement or Recovery
To the fullest extent permitted by law, We are entitled
to the proceeds of any settlement or any judgment
that results in a recovery from a third party, whether
or not responsibility is accepted or denied by the third
party for the condition. We are entitled up to the full
value of the benefits provided by Us for the condition,
calculated using our providers’ usual charges for such
Services, less a percentage of Your counsel’s
reasonable attorney fees that is equal to the
percentage of the total recovery that is payable to Us
whether such benefits are paid by Us before or after
the settlement or recovery. For purposes of this
paragraph, a total attorney fee in excess of one-third
of a total recovery will not be deemed reasonable
absent Our prior agreement. Prior to accepting any
settlement, You must notify Us in writing of any terms
or conditions offered in settlement, and shall notify the
third party of Our interest in the settlement
established by this provision.
What is Third Party Liability/Subrogation and How
Does it Affect You
Third-party liability refers to Claims that are the
responsibility of someone besides LifeWise or You.
Some common examples of third-party liability include
motor vehicle accidents, workplace accidents, injury
or Illness. Third-party liability can also include other
situations involving injury or Illness in which You have
a basis to bring a lawsuit or to make a claim for
compensation against any person or for which You
may receive a settlement such as an injury from a
defective product. Once it has been established that
the third party is responsible to pay and is capable of
paying for the expenses for the Services caused by
that third party, We will not provide benefits for the
Services arising from the condition caused by that
third party.
You must cooperate fully with Us in recovering
amounts paid by LifeWise. If You seek damages
against the third party for the condition and retain an
attorney or other agent for representation in the
matter, then You must agree to require Your attorney
or agent to reimburse LifeWise directly from the
settlement or recovery an amount equal to the total
amount of benefits paid.
You must execute an authorization for Your attorney
or agent to pay LifeWise directly, and cause Your
attorney or agent to execute an agreement in a form
acceptable to Us, by whom Your attorney or agent
agrees to reimburse Us directly from the funds of the
settlement or recovery. We will withhold benefits for
Your condition until a signed copy of this agreement is
delivered to Us. The agreement must remain in effect
and We will withhold payment of benefits if, at any
time, Your authorization or the agreement should be
revoked.
If We make Claim payments on Your behalf for which
a third party is responsible, We are entitled to be
repaid for those payments out of any recovery from
the third party. We will request reimbursement from
You to the extent the third party does not pay Us
directly, and We may request refunds from the
medical providers who treated You, in which case
those providers will bill You for their Services.
“Subrogation” means that We may collect directly
from the third party to the extent We have paid on
Your behalf for third party liabilities. Because We
have paid for Your injuries, we, rather than You, are
entitled to recover for those expenses.
Suspension of Benefits and Reimbursement
After You have received proceeds of a settlement or
recovery from the third party, You are responsible for
payment of all medical expenses for the continuing
treatment of the Illness or injury that LifeWise would
otherwise be required to pay under this policy until all
proceeds from the settlement or recovery have been
exhausted.
We need detailed information from You to accomplish
this process. A questionnaire will be sent to You for
this information. It should be completed and returned
to Our office as soon as possible to minimize any
Claim review delay. If You have any questions or
concerns regarding the questionnaire, please contact
Our office. A specialist in third-party
If You continue to receive medical treatment for the
condition after obtaining a settlement or recovery from
one or more third parties, We are not required to
provide coverage for continuing treatment until You
prove to Our satisfaction that the total cost of the
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 Name of the Member who received the Services
treatment is more than the amount received in
settlement or recovered from the third party, after
deducting the cost of obtaining the settlement or
recovery. We will only cover the amount by which the
total cost of benefits that would otherwise be covered
under this Plan, calculated using Our providers usual
charges for such Services, exceeds the amount
received in settlement or recovery from the third party.
We are entitled to reimbursement from any settlement
or recovery from any third party even if the total
amount of such settlement or recovery does not fully
compensate You for other damages, particularly
including lost wages or pain and suffering; any
settlement arising out of an injury or Illness covered
by this Plan will be deemed first to compensate You
for Your medical expenses, regardless of any
allocation of proceeds in any settlement document
that We have not approved in advance. In no event
shall the amount reimbursed to LifeWise be less than
the maximum permitted by law.
 Name, address, and IRS tax identification number
of the provider
 Diagnosis (ICD) code. You must get this from Your
provider.
 Procedure codes (CPT or HCPCS). You must get
these from Your provider.
 Date of service and charges for each service
Step 3
If You are also covered by Medicare, attach a copy of
the Explanation of Medicare Benefits.
Step 4
Check to make sure that all the information from
Steps 1, 2, and 3 is complete. Your Claim will be
returned if all of this information is not included.
Step 5
Subrogation
Sign the Claim Form.
To the maximum extent permitted by law, We are
subrogated to Your rights against any third party who
is responsible for the condition, have the right to sue
any such third party in Your name, and have a
security interest in and lien upon any recovery to the
extent of the amount of benefits paid by Us and for
Our expenses in obtaining a recovery.
Step 6
Mail Your Claims to:
LifeWise Health Plan of Oregon
PO Box 7709
Bend, OR 97708-7709
Prescription Claims
Right To Receive and Release Necessary
Information
For retail pharmacy purchases, You do not have to
send Us a Claim form. Just show Your LifeWise ID
Card to the pharmacist, who will bill Us directly. If
You do not show Your LifeWise ID card, You will have
to pay the full cost of the prescription. Send Your
pharmacy receipts attached to a completed
Prescription Drug Claim form for reimbursement.
Please send the information to the address listed on
the drug Claim form.
We may, without consent of, or notice to, any person,
release to, or obtain, from any insurance company or
other person or organization any information with
respect to any person deemed to be necessary to
administer benefits unless applicable state or federal
law prevents disclosure of facts without Your consent
or Your representative’s consent. If You claim
benefits under this policy, You must provide
information necessary to implement this provision.
It is very important that You use Your LifeWise ID
card at the time You receive Services from an innetwork pharmacy. Not using Your LifeWise ID card
may increase Your out-of-pocket costs.
SENDING US A CLAIM
Many providers will send Claims to Us directly. When
You need to send a Claim to Us, follow these simple
steps:
Coordination of Benefits for Prescription Claims
If this Plan is the secondary plan as described under
Other Coverage, You must submit Your pharmacy
receipts attached to a completed claim form for
reimbursement. Please send the information to the
address listed under Secondary Prescription Claims
included on the drug claim form.
Step 1
Complete a Claim form. Use a separate Claim form
for each patient and each provider. You can get
Claim forms by calling Customer Service or You can
print them from Our website.
Timely Payment of Claim
Step 2
You should submit all claims within 365 days of the
date You received Services. No payments will be
made by Us for claims received more than 365 days
Attach the bill that lists the Services You received.
Your Claim must show all of the following information:
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after the date of service. Exceptions will be made if
We receive documentation of Your legal
incapacitation. Payment of all claims will be made
within the time limits required.
in part, or not processed within the time shown in this
Benefit Booklet, You may file suit in a state or federal
court.
If You are dissatisfied with Our Denial of Your claim
You may submit a grievance as outlined under
Grievance And Appeals.
Notice Required for Reimbursement and Payment
of Claims
At Our option and in accordance with federal and
state law, We may pay the benefits of this Plan to the
eligible employee, provider, other carrier, or other
party legally entitled to such payment under federal or
state medical child support laws, or jointly to any of
these. Such payment will discharge Our obligation to
the extent of the amount paid so that We will not be
liable to anyone aggrieved by Our choice of payee.
Some Services and supplies covered under this Plan
require Prior Authorization. Please see the Prior
Authorization and Emergency Admission Notification
section of this Benefit Booklet for additional
information.
GRIEVANCE AND APPEALS
As a LifeWise Member, You have the right to offer
Your ideas, ask questions, voice complaints and
request a formal appeal to reconsider decisions We
have made. Our goal is to listen to Your concerns
and improve Our service to You.
Claim Procedure for Groups Subject to the
Employee Retirement Income Security Act of 1974
(ERISA)
We will make every effort to review Your claims as
quickly as possible.
If You need an interpreter to help with oral translation
Services, please call Us. Customer Service will be
able to guide You through the service.
We will send a written notice to You no later than 30
days after We receive Your claim to let You know if
Your plan will cover all or part of the claim. If We
cannot complete the review of Your claim within this
time period, We will notify You of a 15-day extension
before the 30-day time limit ends. If We need more
information from You or Your provider to complete the
review of Your claim, We will ask for that information
in Our notice and allow You 45 days to send Us the
information. Once We receive the information We
need, We will review Your claim and notify You of Our
decision within 15 days.
WHEN YOU HAVE IDEAS
We would like to hear from You. If You have an idea,
suggestion, or opinion, please let Us know. You can
contact Us at the addresses and telephone numbers
found in this Benefit Booklet.
WHEN YOU HAVE QUESTIONS
You can call Us when You have questions about a
benefit or coverage decision, the quality or availability
of a health care service or Our Service. We can
quickly and informally correct errors, clarify benefits,
or take steps to improve Our Service.
If Your claim is denied, in whole or in part, Our written
notice will include:
 The reasons for the denial and a reference to the
plan provisions used to decide Your claim;
We suggest that You call Your provider of care when
You have questions about the health care Services
they provide.
 A description of any additional information needed
to reconsider Your claim and why the information is
needed;
WHEN YOU HAVE A GRIEVANCE
 A statement that You have the right to submit a
grievance or appeal; and
You or Your authorized representative can write to Us
when You have a grievance. Grievance means:
 A description of the Plan’s Grievance or Appeal
processes.
 A complaint in writing about:
 The availability, delivery or quality of a health
care Services;
If there were clinical reasons for the denial, You will
receive a letter from Us stating these reasons.
 Claims payment, handling or reimbursement for
a health care service that is not disputing an
adverse benefit determination; or
At any time, You have the right to appoint someone to
pursue the claims on Your behalf. This can be a
doctor, lawyer, or a friend or relative. You must notify
Us in writing and provide Us with the name, address
and telephone number where Your appointee can be
reached.
We will review Your complaint and notify You of the
outcome as soon as possible, but no later than 30
days.
If a claim for benefits is denied or ignored, in whole or
 A written request for an internal appeal or external
 Concerns about Your health Plan or Us.
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review;
Your Level II internal appeal will be reviewed by a
panel that includes individuals who were not involved
in the Level I appeal. If the adverse benefit
determination involved medical judgment, a health
care provider will be included in the panel. You may
participate in the Level II panel meeting in person or
by phone to present evidence and testimony. Please
contact Us for additional information about this
process.
 An oral or written request for an expedited appeal
or expedited external review.
Grievances for an internal appeal and external review
are described below.
WHEN YOU DISAGREE WITH A BENEFIT
DECISION
If We declined to provide payment or benefits in
whole or in part, and You disagree with that decision,
You have the right to request that We review that
adverse benefit determination through a formal,
internal appeals process.
Once the Level II review is complete, We will provide
You with a written determination. If You are not
satisfied with the final internal appeal decision, You
may be eligible to request an external review, as
described below.
This Plan’s appeal process will comply with any new
requirements as necessary under state and federal
laws and regulations.
Who May File An Internal Appeal?
You or Your authorized representative, an individual
who by law or by consent may act on Your behalf,
may file an appeal. To appoint an authorized
representative, You must sign an authorization form
and mail or fax the signed form to the address or
phone number listed above. This release provides Us
with the authorization for this person to appeal on
Your behalf and allows Our release of information, if
any, to them.
What Is An Adverse Benefit Determination?
An adverse benefit determination means a denial,
reduction, or termination of a health care item or
Services, or a failure or refusal to provide or to make
payment, in whole or in part for a health care item or
Services based on:
 Denial or eligibility for or termination of enrollment
in a Health Benefit Plan;
Please call Us for an Authorization for Appeals form.
You can also obtain a copy of this form on Our
website at lifewiseor.com.
 Rescission of coverage or cancellation of a policy
or certificate. A rescission of coverage means a
retro-active termination or discontinuation of
coverage due to acts of fraud or intentional
misrepresentation of material fact;
How Do I File An Internal Appeal?
You or Your authorized representative may file an
appeal by writing to Us at the address listed below.
We must receive Your appeal request as follows:
 A source or injury exclusion, network exclusion, or
other limitation on otherwise covered benefits;
 For a Level I internal appeal, within 180 calendar
days of the date You are notified of an adverse
benefit determination.
 A determination that a benefit is Experimental,
Investigational, or not Medically Necessary,
effective or appropriate.
 For a Level II internal appeal, within 60 calendar
days of the date You are notified of the Level I
determination.
 A determination that a course or Plan of treatment
is an active course of treatment for purposes of
continuity of care as described under the Covered
Services section of Your Benefit Booklet.
You can mail Your appeal request to:
LifeWise Health Plan of Oregon
Attn: Appeals Department, MS 123
P.O. Box 91102
Seattle, WA 98111-9202
WHEN YOU HAVE AN APPEAL
After You are notified of an adverse benefit
determination, You can request an internal appeal.
Your Plan includes two levels of internal appeals.
Your Level I internal appeal will be reviewed by
individuals who were not involved in the initial adverse
benefit determination. If the adverse benefit
determination involved medical judgment, the review
will be provided by a health care provider. They will
review all of the information relevant to Your appeal
and will provide a written determination. If You are
not satisfied with the decision, You may request a
Level II appeal.
Or, You may fax Your request to:
Appeals Department
(425) 918-5592
If You need help filing an appeal, or would like a copy
of the appeals process, please call Customer Service
at the number listed in the back of this Benefit
Booklet. You can also get a description of the
appeals process by visiting Our website at
lifewiseor.com.
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We will acknowledge Our receipt of Your request in
writing within 5 days.
Appeals Regarding Ongoing Care
If You appeal a decision to change, reduce or end
coverage of ongoing care for a previously approved
course of treatment because the Service or level of
Service is no longer Medically Necessary or
appropriate, We will suspend Our denial of benefits
during the internal appeal period. Our provision of
benefits for Services received during the internal
appeal period does not, and should not be construed
to, reverse Our denial. If Our decision is upheld, You
must repay Us all amounts that We paid for such
Services. You will also be responsible for any
difference between Our allowable charge and the
provider's billed charge.
What If My Situation Is Clinically Urgent?
If Your provider believes that Your situation is
clinically urgent under law, Your appeal will be
conducted on an expedited basis. A clinically urgent
situation means one in which Your health may be in
serious jeopardy or, in the opinion of Your Physician,
You may experience pain that cannot be adequately
controlled while You wait for a decision on Your
appeal. You may request an expedited internal
appeal by calling Customer Service at the number
listed on the back of this Benefit Booklet.
If Your situation is clinically urgent, You may also
request an expedited external review at the same
time You request an expedited internal appeal.
WHEN AM I ELIGIBLE FOR EXTERNAL
REVIEW?
If You are not satisfied with the final internal adverse
benefit determination based on Medical Necessity,
Experimental or Investigational, appropriate health
care setting or level of care, and continuity of care,
You may have the right to have Our decision
reviewed by an Independent Review Organization
(IRO). An IRO is an independent organization of
medical reviewers who are contracted by the Oregon
Insurance Division (OID) and who are qualified to
review medical and other relevant information. There
is no cost to You for an external review.
Can I Provide Additional Information For My
Appeal?
You may supply additional information to support
Your appeal at the time You file an appeal or at a later
date by mailing or faxing to the address and fax
number listed above. Please provide Us with this
information as soon possible.
Can I Request Copies Of Information Relevant To
My Appeal?
You can request copies of information relevant to the
adverse benefit determination. We will provide this
information, as well as any new or additional
information We considered, relied upon or generated
in connection to Your appeal as soon as possible and
free of charge. You will have the opportunity to
review this information and respond to Us before We
make Our decision.
We will send You an external review request form at
the end of the internal appeal process notifying You of
Your right to an external review. We must receive
Your written request for an external review within 180
calendar days of the date You received the final
internal adverse benefit determination. Your request
must include a signed waiver granting the IRO access
to medical records and other materials that are
relevant to Your request.
What Happens Next?
We will review Your appeal and provide You with a
written decision as stated below:
You can request an expedited external review when
Your provider believes that Your situation is clinically
urgent under law. You can also request an expedited
external review of an adverse benefit determination
for mastectomy related Services. Please call
Customer Service at the number listed in the Benefit
Booklet to request an expedited external review.
 Expedited appeals, as soon as possible, but no
later than 72 hours after We received Your request.
We will call, fax or email and will follow up with a
decision in writing.
 Appeals for benefit determinations made prior to
You receiving Services; 15 days of the date We
received Your request
We will notify the OID of Your request for an external
review. The OID will notify You and Us of the IRO
appointed to Your external review. The IRO will let
You, Your authorized representative and/or Your
attending Physician know where additional
information may be submitted directly to the IRO and
when the information must be provided. We will
forward Your medical records and other relevant
materials for Your external review to the IRO. We will
also provide the IRO with any additional information
they request that is reasonably available to Us.
 All other appeals, within 30 days of the date We
received Your request
If We uphold Our initial decision, You will be
provided information about Your right to a Level II
internal appeal or Your right to an external review
at the end of the internal appeals process.
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You can also request an external review by contacting
the OID. Their contact information is listed below
under Other Resources For Help.
ELIGIBILITY AND ENROLLMENT
This section outlines who is eligible for coverage and
who can be covered under this Plan. Only Members
enrolled on this Plan can receive its benefits.
The IRO will review Your request and notify You and
Us of their decision as stated below:
You do not have to be a citizen of or live in the United
States if You are otherwise eligible for coverage.
 Expedited external review, as soon as possible, but
no later than 72 hours after receiving the request.
The IRO will notify You and Us immediately by
phone, e-mail or fax and will follow up with a written
decision by mail.
Employees
To be an employee under this Plan You must:
 Be a permanent employee, sole proprietor, owner,
partner, or corporate officer of the employer/group
who is paid on a regular basis through the payroll
system, and reported to Social Security
 All other external review, within 30 calendar days of
the IRO's receipt of Your request.
What Happens Next?
 Regularly work the minimum hours required by the
Employer/Group Agreement
LifeWise is bound by the decision made by the
IRO. If the IRO overturned Our final internal
adverse benefit determination, We will implement
their decision in a timely manner. If We do not
implement the IRO’s decision You have the right
to sue Us.
 Satisfy any new employee waiting period (Eligibility
Waiting Period), if one is required by the
Employer/Group Agreement
On-call, temporary, substitute and seasonal
employees are not eligible.
If the IRO upheld Our decision, there is no further
review available under this Plan's internal appeals
or external review process. You may have other
remedies available under state or federal law,
such as filing a lawsuit.
Dependents
To be a Dependent under this Plan, the family
Member must be one of the following:
 The employee’s legally recognized Spouse
(Spouse) or Domestic Partner
OTHER RESOURCES TO HELP YOU
If You have questions about understanding a denial of
a Claim or Your appeal rights, You may contact
LifeWise Customer Service for assistance at the
number listed on the back page of Your Benefit
Booklet. If You are not satisfied with Our decisions
and wish to make a complaint or need help filing an
appeal, You can also contact the OID at any time
during this process.
 A child under 26 years of age
A child is:
 A natural offspring of either or both the
employee, Spouse or Domestic Partner
 A legally adopted child of either or both the
employee, Spouse or Domestic Partner
 A child “placed” with the employee for the
purpose of legal adoption in accordance with
state law
If Your Plan is governed by the Federal Retirement
Income Security Act of 1974 (ERISA), You can
contact the Employee Benefits Security
Administration of the U.S. Department of Labor.
 A legally placed ward of the employee, Spouse
or Domestic Partner (including foster children).
There must be a court or other order signed by a
judge or state agency, which grants guardianship
of the child to the employee, Spouse or Domestic
Partner as of a specific date. When the court
order terminates or expires, the child is no longer
an eligible Dependent.
Oregon Insurance Division, Consumer Protection Unit
PO Box 14480
Salem, OR 97309-0405
Call: 503-947-7984 or toll free message line at 888877-4894
Email: [email protected]
On line:
http://www.oregon.gov/DCBS/insurance/gethelp/
Pages/fileacomplaint.aspx
 A grandchild of either or both the employee,
Spouse or Domestic Partner if the mother or
father is a Dependent and enrolled in this Plan
Placement for adoption means the assumption and
retention by an employee of a legal obligation for
total or partial support of a child in anticipation of
the adoption of the child (an individual who has not
attained 18 years of age as of the date of the
adoption or placement for adoption). The child’s
Employee Benefits Security Administration (EBSA)
1-866-444-EBSA (3272)
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placement with an employee ends upon the
termination of such legal obligations.
A Dependent, covered as a child under this Plan,
will remain eligible after age 26 if they are:
can be accomplished as outlined in this section under
Enrollment Provisions For Late And Special
Enrollees.
Domestic Partner And Their Dependents Eligibility
And Enrollment
 Developmentally disabled or permanently
physically handicapped
A Domestic Partner who is not a registered domestic
partner as defined by Oregon statute is eligible for
coverage if an Affidavit of Domestic Partnership has
been properly executed and accepted by the
employer/group.
 Incapable of self-sustaining employment
 Unmarried and primarily Dependent upon the
employee for support
Within 60 days of the Dependent reaching their 26th
birthday, and upon Our request, You must provide
satisfactory proof that the above conditions will
continuously exist on and after this date. Proof will
not be requested more often than annually after
two years from the date the first proof was
furnished. If satisfactory proof is not submitted to
Us, the child’s coverage will not continue beyond
the last date of eligibility.
The Domestic Partner must enroll on forms provided
and/or accepted by us. To obtain coverage, the
Domestic Partner must enroll within 31 days of the
employee’s initial eligibility or the execution of an
Affidavit of Domestic Partnership. If the enrollment
form is not submitted within this time period, the
Domestic Partner and their Dependent children will be
considered late enrollees. Special provisions for late
enrollees are outlined in Your Benefit Booklet under
Who Is Eligible For Coverage.
Enrollment in the Plan
The employee must enroll on forms provided and/or
accepted by Us. To obtain coverage, an employee
must enroll within 31 days after becoming eligible.
Enrollment after this initial time period can be
accomplished as outlined in this section under
Enrollment Provisions For Late And Special
Enrollees.
Employer's that select an HSA benefit option should
check with their tax advisors regarding federal tax
obligations and requirements as a result of the
enrollment of a Domestic Partner or a registered
Domestic Partner as defined by Oregon statute.
Special Conditions Regarding Eligible Family
Dependent Coverage
Dependent enrollment and payment of any necessary
additional Premium must occur within 31 days from
the date of marriage or date of registered domestic
partnership, birth or placement. Enrollment after this
initial time period can be accomplished as outlined in
this section under Enrollment Provisions For Late And
Special Enrollees.
 Employees may cover their Dependents only if they
are also covered and a completed enrollment form
requesting Dependent coverage is received by Us
 If a Spouse becomes an employee of the
employer/group, he or she is no longer a
Dependent and must make application as an
employee
Newborn Child and Adopted Child Eligibility And
Enrollment
WHEN COVERAGE BEGINS
A newborn child of a Member is covered for the first
31 days from the date of birth. Coverage for the
newborn child does not continue beyond the first 31
days of birth unless they also meet the definition of a
Dependent and the child is properly enrolled.
Employee Effective Date
The Effective Date of coverage provision is stated in
the employer/group agreement. It is the first of the
month following completion of the new employee
eligibility waiting period. If You are a late enrollee, as
specified within this section, Your Effective Date of
coverage is described under Special Provisions for
Late Enrollees.
An adopted child is covered for the first 31 days from
the date of placement for the purpose of adoption by
the employee. Coverage for the adopted child does
not continue beyond the first 31 days following
placement unless they also meet the definition of a
Dependent and the child is properly enrolled.
Dependent Effective Date
Each Dependent is eligible for coverage on:
Enrollment and payment of any necessary additional
Premium must occur within 31 days from birth or
placement. If the enrollment and payment are not
accomplished within this time period, medical
Services will not be covered for the child after the
initial 31 days. Enrollment after this initial time period
 The date the employee is eligible for coverage, if
he or she is a Dependent who may be covered on
that date
 The first of the month following the date the
employee is married or is joined in a registered
domestic partnership for any Dependents acquired
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on that date
enroll with LifeWise in lieu of a different health
Plan:
 The date of birth of the natural-born child of the
employee, Spouse or Domestic Partner
 On which You have been covered until that time
 The date the child is placed with the employee,
Spouse or Domestic Partner for the purpose of
adoption
 During an annual group enrollment period
 You have a change in Your family status due to
marriage, birth, adoption or placement for adoption
 The first of the month following the date of a
qualified medical child support court order or
administrative order to provide health coverage for
a child of an employee or employee’s Spouse or
Domestic Partner
If You qualify as a special enrollee, You may enroll
during a special enrollment period.
Special Enrollment Periods
If You or Your Dependents qualify as a special
enrollee, You may enroll in this Plan during the
special enrollment period. The special enrollment
period has terms and conditions which are specific to
the following circumstances. An employee must have
satisfied the new employee waiting period before they
can enroll during a special enrollment period.
 The first of the month following the date an Affidavit
of Domestic Partnership has been properly
executed and accepted by employer/group for a
Domestic Partner and the Domestic Partner's
Dependents
ENROLLMENT PROVISIONS FOR LATE AND
SPECIAL ENROLLEES
Special Enrollees Who Have Lost Their Other
Coverage
There are special provisions for enrollment in this
Plan if You or Your Dependents did not enroll in this
Plan when first eligible. When and how You are able
to enroll is determined by whether You qualify as a
special or a late enrollee as described within this
provision.
If You have declined enrollment for yourself or Your
Dependents (including Your Spouse) because of
other group health coverage, You may enroll yourself
and Your Dependents under the terms of this Plan.
To do so, You must request enrollment within 30 days
after the other coverage ends and each of the
following conditions must be met:
Late Enrollees
A “late enrollee” is an individual or Dependent who did
not enroll when first eligible for coverage under this
Plan and does not qualify as a special enrollee. If
You or Your Dependents are late enrollees, You or
Your Dependents may enroll during the next occurring
annual group enrollment period.
 The person was covered under a health Plan at the
time coverage under this Plan was previously
offered
 The person stated in writing that coverage under
such group health Plan or health insurance
coverage was the reason for declining enrollment;
but only if We required such a statement and
provided the person with notice of such
requirement (and the consequences of such
requirement) at such time
Special Enrollees
If an eligible individual qualifies as a “special
enrollee”, that person is allowed to enroll in the Plan
within specific guidelines as outlined within this
provision. You or Your Dependent qualify as a
“special enrollee” if:
And if the other coverage was:
 Under a COBRA continuation provision and the
coverage under such a provision was exhausted.
Failure to pay Premium or termination of coverage
for cause do not satisfy this requirement
 You declined coverage with this Plan at the time
You were first eligible for coverage because You
had coverage under another health Plan, Medicaid,
Medicare, CHAMPUS, Indian Health Services,
Oregon Health Plan or another publicly sponsored
or subsidized health Plan, and that coverage has
since ended
 Not under a COBRA Continuation provision and
either the coverage was terminated as a result of:
 Loss of eligibility for the coverage, including
legal separation; divorce; death; termination of
employment; or
 You apply for coverage during a special enrollment
period
 Reduction in the number of hours of
employment, children aging out of coverage, or
 There is a court order that is not more than 30 days
old ordering that a Spouse or minor child be
covered under this Plan
 Moving out of an HMO Service Area and there is
no other coverage available with the other Plan.
 You are employed by an employer who offers
multiple Health Benefit Plans and You elect to
 Failure to pay Premium or termination of coverage
for cause do not satisfy this requirement.
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 The current or former employer contributions
towards such coverage were terminated
 You no longer qualify for health care coverage
under the Oregon Health Plan or CHIP
 The person requests enrollment under this Plan not
later than 30 days after the date such other
coverage ended
If You and/or Your Dependents are eligible as
outlined above, You qualify for a 60-day special
enrollment period. This means that You must request
enrollment in this Plan within 60 days of the date You
qualify for Premium assistance under the Oregon
Health Plan or CHIP or lose Your Oregon Health Plan
or CHIP coverage.
The coverage will become effective on the first of the
month following Our receipt of the enrollment
application. If We do not receive the enrollment
application within 30 days of the date prior coverage
ended, You will be considered a late enrollee.
Coverage under this Plan for the employee or
Dependent will start on the first of the month
following:
Special Enrollees Who Have A Change In Family
Status
 The date the employee or Dependents qualify for
the Oregon Health Plan or CHIP Premium
assistance
Individuals who previously declined enrollment in this
Plan and have a change in family status may be
eligible to enroll in this Plan as a special enrollee.
Marriage, birth or adoption of a child is considered to
be a change in family status. There are specific terms
and conditions that must be followed in order to enroll
during a special enrollment period. An employee may
cover their Dependents only if they are also covered.
In addition to the eligibility provisions contained in this
Plan, the following shall also apply:
 The date the employee or Dependents lose
coverage under the Oregon Health Plan or CHIP
The employee and/or Dependents may be required to
provide proof of eligibility from the state for this
special enrollment period.
If We do not receive the enrollment application within
the 60-day period as outlined above, the applicant will
be considered a late enrollee.
The special enrollment period is 30 days and begins
on the later of:
CHANGES IN COVERAGE
 The date Dependent coverage is made available
under this Plan
No rights are vested under this Plan. Its terms,
benefits, and limitations may be changed at any time.
All changes to this Plan will apply, as of the date the
change becomes effective to all Members and to
employees and Dependents that become covered
under this Plan after the date the change becomes
effective.
 The date of the marriage, birth, or adoption or
placement for adoption
Following Our receipt of the enrollment application,
the coverage will become effective as follows:
 In the case of marriage, on the first day of the first
calendar month following Our receipt of the
enrollment request; or on an earlier date as agreed
to by Us
DISCONTINUANCE AND REPLACEMENT OF
GROUP COVERAGE
If a person was covered under the employer’s prior
group policy or contract on the date of termination of
that group policy or contract and is eligible for
coverage under this contract, that person shall be
eligible for coverage under this contract without
regard to active status or Hospital confinement.
 In the case of a Dependent’s birth, on the date of
such birth
 In the case of a Dependent’s adoption or
placement for adoption, the date of such adoption
or placement for adoption
If We do not receive the enrollment application within
30 days of the date of the family status change, You
will be considered a late enrollee.
The following will govern such coverage:
 The minimum level of benefits to be provided by Us
shall be the applicable level of benefits of this
contract reduced by any benefits payable by the
prior policy or contract. We will provide such
coverage until the date on which Your coverage
would terminate as described in the Termination of
Coverage section. The Discontinuance and
Replacement of Group Coverage provision will not
apply to an individual who is covered under another
contract with similar benefits.
Special Enrollees With Medicaid (Oregon Health
Plan) and Children’s Health Insurance Program
(CHIP) Premium Assistance
You and Your Dependents may have special
enrollment rights under this Plan if You meet the
eligibility requirements described under Who Is
Eligible For Coverage, and:
 You qualify for Premium assistance for this Plan
from the Oregon Health Plan or CHIP
 In applying any deductibles or benefit exclusion
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 The end of the period for which required Premium
was due to Us and not received by us
periods of the prior Plan, We will credit any
applicable deductibles actually incurred by You and
will credit the time period satisfied towards any
applicable benefit exclusion periods. This means
the deductible credit shall be given only to the
extent the expenses are recognized under the
terms of this Plan and are subject to a similar
deductible.
 For the employee, the end of the month following
the date he or she no longer qualifies as an
employee or terminates employment with the
employer/group
 For the employee, the end of the month he or she
fails to pay required Premiums
 If You are confined in a facility on Your Effective
Date of coverage with this Plan, and the employer
replaces that prior group coverage with this Plan,
benefit availability for Services may be affected. If
You are hospitalized on the day of termination of a
prior policy or contract and are covered under this
Plan, Your benefits under the prior Plan will affect
the benefits of this Plan for that hospitalization until
the confinement ends or Hospital benefits under
the prior policy or contract are exhausted,
whichever is earlier.
 For the employee, the end of the month following
the date he or she fails to be in an eligible class of
persons as shown on the Employer/Group
Agreement and as described in the
Employer/Group Provisions
 For the employee, the end of the month following
the date the employee retires;
 The end of the month following the date the
employee requests termination of coverage to be
effective for the employee or Member
ELIGIBILITY STATUS CHANGES DUE TO
LEAVE OF ABSENCE, LAYOFFS AND
REDUCTION IN WORK HOURS
 For a Dependent, the date the employee’s
coverage terminates
 For a Dependent, the end of the month following
the date he or she no longer qualifies as a
Dependent
An employee on an employer approved leave of
absence, for any reason, may continue to be covered
under this contract as though in active status, at the
employer’s option, for a period not to exceed three (3)
months. Absences extending beyond this time period
will be subject to the provisions outlined under
continuation coverage.
 For You or the employer/group, the date We
discover any breach of contractual duties,
conditions or representations,
 For You or the employer/group, the end of the
month following the date the employer/group
terminates its participation in a multiple employer
trust or association
An employee who has been laid off and rehired within
nine (9) months shall be covered on the first of the
month following their return to work, provided that an
enrollment application is completed by the employee
and received by Us within 31 days of returning to
work.
 For a Domestic Partner and their Dependents, the
end of the month following the date there is a
change in one or more of the circumstances as
listed on the Affidavit of Domestic Partnership
An employee who lost eligibility due to a reduction in
work hours shall be covered on the first of the month
following the date the employee regains eligibility
provided that an enrollment application is completed
by the employee and received by Us within 31 days of
becoming eligible.
We may rescind Your coverage upon the discovery of
fraud or material misrepresentation of material fact
regarding any terms, conditions or benefits of the
contract.
You and the employer/group are responsible to
advise Us of any changes in eligibility including the
lack of eligibility of a family Member. Coverage will
not continue beyond the last date of eligibility
regardless of the lack of notice to Us.
For the employee, a leave of absence granted under
the federal Family and Medical Leave Act of 1993 or
the Uniformed Services Employment and
Reemployment Rights Act of 1994 is administered in
accordance with these acts and this contract.
Non-Liability after Termination
Upon termination of this contract, We shall have no
further liability beyond the Effective Date of the
termination except as stated below. We will provide
information to the employer/group so they can inform
Members of the termination of this contract. It will be
the employer/group's responsibility to inform all
Members that this contract has terminated.
TERMINATION OF COVERAGE
WHEN COVERAGE ENDS
Termination of coverage will occur on the earliest
of the following:
 The date this contract terminates
If the employer/group has immediately replaced this
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contract with another insurer's contract or group
policy and a Member is hospitalized at the time of this
termination, he or she shall continue to receive
benefits for Services he or she received for that
hospitalization until discharged from the Hospital or
until the limits of coverage under this contract have
been reached, whichever is earlier.
State mandated continuation of coverage is also
available to any enrolled Dependent if they were
enrolled in this Plan on the day before the employee’s
termination of employment or membership.
Who May Be Eligible
The enrolled employee or enrolled Dependent may be
eligible for continuation of coverage if:
CONTINUATION OF COVERAGE
 Coverage ends because of the termination of
employment of the employee
There are specific requirements, time frames and
conditions which must be followed in order to be
eligible for continuation of coverage and which are
generally outlined below. Please contact Your
employer/group as soon as possible for details if You
think You may qualify for continuation of coverage.
 Coverage ends because the employee’s reduction
in work hours
 Coverage ends because of the death, dissolution of
marriage or domestic partnership, or legal
separation
FOR GROUPS WITH 20 OR MORE EMPLOYEES
 Coverage ends because the employee becomes
eligible for Medicare
If You become ineligible You may continue coverage
to the extent required by the federal Consolidated
Omnibus Budget Reconciliation Act of 1986,
(COBRA) as amended, and Oregon state law. You
may be eligible to continue coverage on a self-pay
basis for 18 or 36 months through COBRA. COBRA
is a federal law which requires most employers with
20 or more employees to offer continuation of
coverage. How long You may continue coverage on
COBRA will depend upon the circumstances which
caused You to lose Your coverage on the group Plan.
 Coverage ends because the enrolled Dependent
no longer qualifies as a Dependent
You must request state continuation of coverage in
writing and pay Your Premium to Your employer
within 31 days after the date on which Your coverage
under this contract would otherwise end.
Maximum Length of Coverage
State continuation of group coverage terminates the
earlier of:
Special Notice
 Nine (9) months after the date on which the
enrolled employee’s coverage under this contract
otherwise would have ended because of
termination of employment or membership.
If You are a Member and a surviving, divorced or
legally separated Spouse of an enrolled employee,
and at least 55 years old at the employee's time of
death or at the time of the dissolution or legal
separation, You may be eligible to continue coverage.
This state-mandated continuation of coverage will
terminate upon the earliest of any of the following:
 Nine (9) months after the start of a leave of
absence from which an enrolled employee does not
return to work.
 Nonpayment: The end of the month for which You
last made timely payment (30 days from the date
the Premium is due).
 The failure to pay Premiums when due, including
any grace period
 The date that the contract is terminated
 Medicare: First of the month in which You become
eligible to Medicare benefits.
 The date on which the Spouse becomes insured
under any other group health Plan
 Other group coverage: The date You become
covered under another group health Plan as a
covered employee or as a Dependent.
 The date on which the Spouse remarries and
becomes covered under another group health Plan
 Remarriage: The date the former Spouse
remarries and, because of the remarriage,
becomes covered under another group health Plan.
 The date on which the Spouse becomes eligible for
federal Medicare coverage
FOR GROUPS NOT SUBJECT TO COBRA OR
WITH FEWER THAN 20 EMPLOYEES
Continuation of Benefits during Labor Strike
If Premiums are paid by Your employer/group under
the terms of a collective bargaining agreement and
there is a cessation of work by the employees due to
a strike or lockout, this contract will continue in effect
if the employer/group continues to pay the Premium
due. The union which represents the employer/group
State mandated continuation of coverage is available
to the employee if they have been covered
continuously under this contract, or a similar
predecessor group health Plan, during the three
month period prior to the date of termination of
employment or membership.
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is responsible for collecting and paying the Premium
by the due date. The amount payable by each
employee shall be the Premium for the category in
which the employee belongs plus a maximum of 20%
increase to pay the increased cost by us. Nothing in
this paragraph shall be deemed to limit any right We
may have in accordance with the terms of this
contract to increase or decrease the Premium.
Benefit Booklets
LifeWise will furnish Benefit Booklets to the
employer/group for delivery to each employee. If
Dependents are enrolled, only one Benefit Booklet will
be issued for each family unit.
Choice of Law
The laws of the State of Oregon govern the
interpretation of this contract. The laws of the state in
which this contract is executed governs the
administration of benefits to Member beneficiaries of
this contract. Oregon law will govern the
interpretation of any requirements applicable to
Members who are out-of-area or who reside out of the
Service Area.
Coverage under this paragraph shall continue until
the first of the following occurs:
 Less than 75% of employees, at the time of
cessation of work, continue coverage
 Nine (9) months after cessation of work
 For an individual employee and Dependents, the
time at which the employee takes full time
employment with another employer
Conformity with the Law
The contract is issued and delivered in the state of
Oregon. This Plan conforms with the 10 essential
benefits and is consistent with the requirements of the
Affordable Care Act (federal health care reform). It is
governed by the laws of Oregon, except to the extent
preempted by federal law. If any part of this contract
or any Endorsement to it is found to be in conflict with
state or federal laws or regulations, then We will
administer this contract to comply with those laws and
regulations as of their Effective Date.
Continuation of Benefits after Injury or Illness
Covered by Worker's Compensation Insurance
Coverage under this contract shall be available to
employees who are not actively working and are
receiving Worker's Compensation insurance
payments. Premium payment due will remain the
same as if the employee was actively at work. This
continuation of benefits is administered in accordance
with the coverage extensions provision and with any
state or federal continuation requirements. The
employee may maintain such coverage until the
earlier of:
Duplicating Provisions
If any charge is covered under two or more benefits,
We will pay only under the provision allowing the
greater benefit. We may calculate based upon both
the amounts already paid and the amounts due to be
paid. We have no liability for benefits other than
those this contract provides.
 The employee takes full-time employment with
another employer
 Nine (9) months from the date that the payment of
Premium is made under this provision.
Coverage Extensions
Employer/Group As The Agent
Coverage extensions refer to the extension of full
coverage for You and any family Members during
which the employer/group agrees to pay any portion
of Your cost of coverage under the terms of any
collective bargaining agreements, contract, other
agreements or contract provisions. The coverage
extension follows an event which otherwise would
qualify as a qualifying event under federal law
requiring COBRA continuation coverage. You and
Your covered Dependents shall continue to be
Members during such period, but such period shall be
deducted from Your entitlement to COBRA
continuation coverage under this contract to the same
extent as federal law gives credit to the
employer/group against the maximum coverage
period under federal law.
The employer/group is the agent of the Members for
all purposes under this contract and not the agent of
LifeWise. Any action taken by the employer/group will
be binding on you.
Employer/Group Records
The employer/group is responsible for keeping
accurate records relating to this contract. The records
must contain all the information We need to
administer this contract. We have the right to request,
inspect or audit the employer/group’s records at any
reasonable time during regular business hours.
Entire Contract
This entire contract between You and LifeWise
includes all of the following:
OTHER PLAN INFORMATION
 This Benefit Booklet
 The Employer/Group Provisions
In this section, We have listed other Plan provisions
and State and Federal Notices.
 The Small Employer Group Agreement and Benefit
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Selections form
surveys
 All Endorsements included now or issued later
You may also request a copy of Our Annual
Summaries from the Department of Consumer and
Business Services. You can contact them as follows:
Failure To Provide Information Or Providing
Incorrect Or Incomplete Information
By calling: (503) 947-7984 or their toll-free message
line at: (888) 877-4894
The employer/group and Members warrant that all
information contained in applications, questionnaires,
forms, or statements submitted to Us to be true,
correct, and complete. If You willfully fail to provide
information required to be provided under this
contract or knowingly provide incorrect or incomplete
information, then Your rights and those of all other
Members of Your family unit may be terminated as
described in the contract.
By writing to: Consumer Protection Unit
350 Winter Street NE, Room 440
Salem, OR 97301-3883
Through the internet at:
http://www.cbs.state.or.us/external/ins
By email at: [email protected].
In addition, if the employer/group fails to furnish
information as required to be furnished under terms of
this contract, the employer/group will indemnify,
defend, save and hold harmless LifeWise from any
lawsuits, demands, Claims, damages or other losses
arising from the employer/group's failure to inform Us
or Members of such required information.
Interpretation of Plan
To the extent this Plan is governed by the Employee
Retirement Income Security Act of 1974 (ERISA), as
amended, the employer’s responsibilities and Our
responsibilities include the following:
 The employer is responsible for furnishing
summary plan descriptions, annual reports and
summary annual reports to Plan participants and to
the government as required by ERISA
Fraudulent Claims
If a Member claims benefits for which no care, service
or supply is received, the Claims will be denied. If
benefits are paid in error under this policy due to any
intentionally false or misleading statements of
material fact under the terms of this policy, We will be
entitled to recover amounts paid in error.
 The employer and not LifeWise is the “Plan
Administrator" as defined in ERISA
 The employer is responsible for providing all
notices regarding continuation
 The employer has delegated authority to LifeWise,
as part of the routine operation of the plan to
reasonably apply the terms of the contract for
making decisions as they apply to specific
eligibility, benefits and claims situations
Independent Contractors
When healthcare providers and facilities provide
Services under their contract with Us, they are acting
as independent contractors. They are not Our
employees or agents. We are not legally responsible
for any harm that comes to a Member while in a
provider’s care. This includes, without limitation, any
general damages, pain and suffering.
Legal Action
No legal action may be brought to recover benefits
from this contract until You have a final decision from
the Grievance and Appeals provision. No more than
3 years after the date We denied, in writing, the rights
or benefits claimed under this Plan or the date the
independent review process ends, if applicable.
Information About LifeWise
Information listed below regarding LifeWise Health
Benefit Plans is available upon request. Please
contact Us at 800-596-3440 and You will be directed
to the area which can best answer Your questions.
LifeWise ID Card
The LifeWise ID card is issued by LifeWise for
Member identification purposes only. It does not
confer any right to Services or other benefits under
this contract.
The following disclosures are available:
 LifeWise drug formularies
 LifeWise process for credentialing in-network
providers and their qualifications
LifeWise Privacy Policy and Notification Practices
 LifeWise Annual Summary of Network Adequacy
We may collect, use, or disclose (give out) information
about You. This protected personal information (PPI)
may include health information, or personal data such
as Your address, telephone number or Social Security
number. We may get this information from, or give it
out to, health-care providers, insurance companies, or
 LifeWise Annual Summary of Grievance and
Appeals
 LifeWise Annual Summary of Utilization Review
Policies
 The results of all publically available accreditation
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other groups.
misunderstanding, misinterpretation or lack of
knowledge of the terms, provisions and benefits of
this policy. If You have any questions or are unclear
about any provision concerning this Plan, please
contact Us. We will help You in understanding and
complying with the terms of Your Plan.
We collect, use, or give out this information for routine
business operations such as these:
 Determining Your eligibility for benefits and paying
Claims
 Obtaining benefit information You receive from
other health-care Plans
Misstatement of Age
 Care management, personal health support
programs, utilization or quality reviews
If the insured’s age was not correct, the Premium will
be adjusted to the correct age.
 Meeting other legal obligations that are specified
under this policy
Modification and Notice of Plan Change
A written notice to the policyholder is required for any
modifications or changes to this contract. No such
change shall be made by LifeWise in this policy
unless the same change is made in all policies of the
same form and class. Written notice at times other
than at renewal will be made 60 days in advance of
any material modification made to the Plan.
This information may also be collected, used or
released as required or permitted by law.
At times We may give out Your PPI when it is not
related to a routine business function. When We do
this, We remove any information that could easily
identify You, or We get Your permission in writing
ahead of time.
Credit will be applied to benefit maximum limits,
durational limits, deductibles and out-of-pocket
maximums if the benefits for Covered Services under
this policy are modified, or if You change to another
LifeWise policy. However credit is given only to the
extent that these provisions are applicable under the
terms of the policy prior to the modification or change.
You have the right to look at or change any records
We have that contain Your PPI. To do this, contact
Customer Service and ask Us to mail a request form
to You.
Our detailed Notice of Information Practices is
available upon request. Please call Us at the number
listed in the front of this contract to request a copy.
Any notice required of Us under this Plan shall be
deemed to be sufficient if mailed to the Member at the
address appearing on the records of LifeWise. Any
notice required of the policyholder shall be deemed
sufficient if mailed to the office of LifeWise Health
Plan of Oregon, P.O. Box 7709, Bend, Oregon
97708-7709.
Member Rights and Responsibilities
We are committed to treating Members in a manner
that respects their rights. Our Members have the right
to receive information about Our organization, the
Services We provide, and their rights and
responsibilities under Our Plan. Members also have
the right to get information about LifeWise providers
and participate in decision making about their health
care. They also have the right to have a candid
discussion with their provider about appropriate or
Medically Necessary treatment options for their
condition(s) no matter the cost of benefit coverage.
They have the right to be treated with respect and
dignity and to have their privacy recognized. They
also have the right to voice complaints and
grievances about Our organization or the care
provided to them.
Newborn’s and Mother’s Health Protection Act
Group health Plans and health insurance issuers
generally may not, under federal law, restrict benefits
for any hospital length of stay in connection with
childbirth for the mother or newborn child to less than
48 hours following a vaginal delivery, or less than 96
hours following a cesarean section. However, federal
law generally does not prohibit the mother’s or
newborn’s attending provider, after consulting with the
mother, from discharging the mother or her newborn
earlier than 48 hours (or 96 hours as applicable). In
any case, group health Plans and health insurance
issuers may not, under federal law, require that a
provider obtain authorization from the Plan or the
insurance issuer for prescribing a length of stay not in
excess of the 48 hours (or 96 hours).
You are responsible for supplying providers with
information necessary for the providers to determine
appropriate medical Services. You are also
responsible for following instructions and guidelines
that You have agreed upon with Your providers and
for doing their part to maintain an effective
patient/provider relationship.
Non-Transferability of Benefits
No person other than a Member is entitled to receive
benefits under this contract. Such right to benefits is
non-transferable.
It is Your responsibility to read and to understand the
terms of this policy. We will have no liability for Your
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Non-Waiver
 An Illness, except for infection of a cut or wound
No delay or failure when exercising or enforcing any
right under this contract shall constitute a waiver or
relinquishment of that right and no waiver or any
default under this contract shall constitute or operate
as a waiver of any subsequent default. No waiver of
any provision of this contract shall be deemed to have
been made unless and until such waiver has been
reduced to writing and signed by the party waiving the
provision.
 Over-exertion or muscle strains
 Dental injuries caused by biting or chewing
Ambulatory Surgical Facility
A healthcare facility where people get surgery without
staying overnight. An ambulatory surgical center
must be licensed or certified by the state it is in. It
also must meet all of these criteria:
 It has an organized staff of Physicians
Recovery of Claims Overpayments
 It is a permanent facility that is equipped and run
mainly for doing surgical procedures
We have the right to recover money We overpay in
error. We may recover this money from the
policyholder or anyone else that was paid, including a
provider. We may deduct the money from future
benefits of the employee or any of his or her
Dependents (even if the original payment was not for
that Member). We can only do this if We would
otherwise pay those benefits directly to the subscriber
or to a provider that does not have a contract with Us.
We will do any recovery no later than 365 days after
the original Claim is settled.
 It does not provide Inpatient Services or rooms
Benefit Booklet
Benefit Booklet describes the benefits, limitations,
exclusions, eligibility and other coverage provisions
included in this Plan and is part of the entire contract.
Calendar Year (Year)
A 12-month period that starts each January 1, at
12:01 a.m., and ends on December 31, at midnight.
Severability
Chemical Dependency
Invalidation of any term or provision herein by
judgment or court order shall not affect any other
provisions, which shall remain in full force and effect.
Dependent on or addicted to drugs or alcohol. It is an
Illness in which a person is dependent on alcohol
and/or a controlled substance regulated by state or
federal law. It can be a physiological (physical)
dependency or a psychological (mental) dependency
or both. People with Chemical Dependency usually
use drugs or alcohol in a frequent or intense pattern
that leads to:
Workers’ Compensation Insurance
This contract is not in lieu of, and does not affect, any
requirement for coverage by Workers’ Compensation
insurance.
 Losing control over the amount and circumstances
of use
Women’s Health and Cancer Rights Act of 1998
Your Plan, as required by the Women’s Health and
Cancer Rights Act of 1998 (WHCRA), provides
benefits for mastectomy-related Services including all
stages of reconstruction and surgery to achieve
symmetry between the breasts, prostheses, and
complications resulting from a mastectomy, including
lymphedemas. Please see the Covered Services
section.
 Developing a tolerance of the substance, or having
withdrawal symptoms if they reduce or stop the use
 Making their health worse or putting it in serious
danger
 Not being able to function well socially or on the job
Chemical Dependency includes drug psychoses and
drug dependence syndromes.
DEFINITIONS
Claim
Some words We use to describe this Plan have
special meanings in the Benefit Booklet. The
information here will help You understand what these
words mean. To help You know which words are
defined, We have capitalized the defined words
throughout this Benefit Booklet.
A request for payment from Us according to the terms
of this Plan.
Coinsurance
The amount You pay for Covered Services after You
meet Your deductible. Coinsurance is always a
percentage of the allowable amount. Coinsurance
amounts are listed in the Summary of Your Costs.
Accidental Injury
Physical harm caused by a sudden, unexpected event
at a certain time and place.
Complications of Pregnancy
Accidental Injury does not mean any of the following:
A medical condition related to pregnancy or childbirth
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that falls into one of these three categories:
one of the following:
 A condition of the fetus that needs surgery while
still in the womb (in utero surgical intervention)
 Group coverage, including the Federal Employees
Health Benefits Plan, State Children’s Health
Insurance Program and the Peace Corps
 A disease the mother has that is not caused by the
pregnancy but is made worse by the pregnancy
 Individual coverage
 A condition the mother has that is caused by the
pregnancy and is more difficult to treat because of
the pregnancy. These conditions are limited to:
 Student health Plan
 Medicare, Medicaid, TRICARE
 Indian Health Services or tribal organization
coverage
 Ectopic pregnancy
 Hydatidiform mole/molar pregnancy
 State high-risk pool
 Incompetent cervix that requires treatment
 Public health Plan established or maintained by a
state, the U.S. government, a foreign country, or
any political subdivision of a state, the U.S.
government or a foreign country
 Complications of administration of anesthesia or
sedation during labor or delivery
 Obstetrical trauma uterine rupture before onset
or during labor
Custodial Care
 Hemorrhage before or after delivery that requires
medical/surgical treatment
Any part of a Service, procedure, or supply that is
mainly to:
 Placental conditions that require surgical
intervention
 Maintain Your health over time, and not to treat
specific Illness or injury
 Preterm labor and monitoring
 Help You with activities of daily living. Examples
are help in walking, bathing, dressing, eating, and
preparing special food. This also includes
supervising the self-administration of medication
when it does not need the constant attention of
trained medical providers.
 Toxemia
 Gestational diabetes
 Hyperemesis gravidarum
 Spontaneous miscarriage or miss abortion
A complication of pregnancy requires Covered
Services that are beyond or greater than the usual
maternity Services. This includes care before, during,
and after birth (normal or cesarean).
Dentally Necessary
Those Covered Services which are determined to
meet all of the following requirements:
Copay (Copayment)
 Essential to, consistent with, and provided for the
diagnosis or the direct care and treatment of a
disease, Accidental Injury, or condition harmful or
threatening to the Member’s dental health, unless
provided for preventive Services when specified as
covered under this Plan
A Copay is a set dollar amount You must pay Your
provider. You pay a Copay at the time You get care.
 Appropriate and consistent with authoritative dental
or scientific literature
Cosmetic Service
 Not primarily for the convenience of the Member,
the Member’s family, the Member’s dental care
provider or another provider
Congenital Anomaly
A body part that is clearly different from the normal
structure at the time of birth.
Services that are performed to reshape normal
structures of the body in order to improve or alter
Your appearance or improve Your self-esteem and
not primarily to restore an impaired function of the
body.
Dental Emergency
A dental emergency means an oral condition
occurring suddenly, requiring urgent professional
attention due to trauma and/or pain caused by a
sudden unexpected injury, acute infection or similar
occurrence.
Covered Service
A Service, supply or drug that is eligible for benefits
under the terms of this Plan.
Dependent
Creditable Coverage
The employee’s Spouse or Domestic Partner and any
children who are enrolled on this Plan.
Coverage You had that ended no more than 63 days
before Your Effective Date or coverage You still have
on Your Effective Date. The other coverage must be
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Detoxification
Endorsement
Detoxification is active medical management of
medical conditions due to substance intoxication or
withdrawal, which requires repeated physical
examination appropriate to the substance ingested
and medication. Observation alone is not active
medical management.
A document that is attached to and made a part of
this contract. An Endorsement changes the terms of
the contract.
Essential Health Benefits
Essential health benefits are services defined as such
by the Secretary of the U.S. Department of Health
and Human Services. Essential health benefits fall
into the following categories:
Domestic Partner
A person who is not a registered domestic partner as
defined by Oregon statute, and for whom an Affidavit
of Domestic Partnership has been properly executed
and accepted by the employer/group.
 Ambulatory patient services
 Emergency services
 Hospitalization
See Spouse for registered Domestic Partners as
defined by Oregon statute.
 Maternity and newborn care
 Mental health and substance use disorder services,
including behavioral health treatment
Effective Date
The date Your coverage under this Plan begins.
 Prescription drug
Emergency Medical Condition
 Rehabilitation and habilitation services and devices
A medical condition that manifests itself by symptoms
of sufficient severity that a prudent layperson
possessing an average knowledge of health and
medicine would reasonably expect that failure to
receive immediate medical attention would:
 Laboratory Services
 Preventive and wellness services and chronic
disease management
 Pediatric Services, including oral and vision care, if
applicable
 Place the health of a person, or an unborn child in
the case of a pregnant woman, in serious jeopardy
Experimental/Investigational Procedures
 Result in serious impairment to bodily functions
Services that meet one or more of the following:
 With respect to a pregnant woman who is having
contractions, for which there is inadequate time to
affect a safe transfer to another Hospital before
delivery or for which a transfer may pose a threat to
the health or safety of the women or the unborn
child
 A drug or device which cannot be lawfully marketed
without the approval of the U.S. Food and Drug
Administration and does not have approval on the
date the Service is provided
Emergency Medical Screening Exam
 There is no reliable evidence showing that the
service is effective in clinical diagnosis, evaluation,
management or treatment of the condition
 It is subject to oversight by an Institutional Review
Board
The medical history, examination, ancillary tests and
medical determinations required to ascertain the
nature and extent of an Emergency Medical
Condition.
 It is the subject of ongoing clinical trials to
determine its maximum tolerated dose, toxicity,
safety or efficacy
Emergency Services
 Evaluation of reliable evidence indicates that
additional research is necessary before the service
can be classified as equally or more effective than
conventional therapies
 Services and supplies including ancillary Services
given in an emergency department
 Examination and treatment as required to stabilize
a patient to the extent the examination and
treatment are within the capability of the staff and
facilities available at a Hospital. Stabilize means to
provide medical treatment necessary to ensure
that, within reasonable medical probability, no
material deterioration of an Emergency Medical
Condition is likely to occur during or to result from
the transfer of the patient from a facility; and for a
pregnant woman in active labor, to perform the
delivery.
Reliable evidence means only published reports and
articles in authoritative medical and scientific
literature, scientific results of the provider of care’s
written protocols, or scientific data from another
provider studying the same Service.
Health Benefit Plan
A hospital expense contract or certificate, health care
service contractor or health maintenance organization
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subscriber contract, any Plan provided by a multiple
employer welfare arrangement or by any other benefit
arrangement defined in the federal Employee
Retirement Income Security Act of 1974, as
amended.
Services that are at least as likely to produce
equivalent therapeutic or diagnostic results for the
diagnosis or treatment of that patient’s Illness,
injury or disease.
Hospital
For these purposes, “generally accepted standards of
medical practice” means standards that are based on
credible scientific evidence published in peer
reviewed medical literature. This published evidence
is recognized by the relevant medical community,
Physician specialty society recommendations and the
views of Physicians practicing in relevant clinical
areas and any other relevant factors.
A healthcare facility that meets all of these criteria:
Member
 It operates legally as a Hospital in the state where it
is located
Any person covered under this Plan.
Home Medical Equipment (HME)
Equipment ordered by a health care provider for
everyday or extended use to treat an Illness or injury.
HME may include: oxygen equipment, wheelchairs or
crutches.
Mental or Nervous Conditions
 It has facilities for the diagnosis, treatment and
acute care of injured and ill persons as Inpatients
Mental or Nervous Conditions means all mental
health disorders and listed in the Diagnostic and
Statistical Manual of Mental Disorders (DSM) Fourth
Edition, DSM-IV-TR or the Diagnostic and Statistical
Manual (DSM), Fifth Edition, DSM-5..
 It has a staff of doctors that provides or supervises
the care
 It has 24-hour nursing Services provided by or
supervised by registered nurses
Off Label Prescription Drugs
A facility is not considered a Hospital if it operates
mainly for any of the purposes below:
Off label use of Prescription Drugs is when a drug is
prescribed for a different condition than the one it was
approved for.
 As a rest home, nursing home, or convalescent
home
 As a residential treatment center or health resort
Orthotic
 To provide hospice care for terminally ill patients
A support or brace applied to an existing portion of
the body for weak or ineffective joints or muscles, to
aid, restore or improve function.
 To care for the elderly
 To treat Chemical Dependency or tuberculosis
Outpatient
Illness
A person who gets health care Services without an
overnight stay in a health care facility. This word also
describes the Services You get while You are an
Outpatient.
A sickness, disease, medical condition or
complication of pregnancy.
Inpatient
Someone who is admitted to a health care facility for
an overnight stay. We also use this word to describe
the Services You get while You are an Inpatient.
Pervasive Developmental Disorder
Medically Necessary and Medical Necessity
Physician
Services a Physician, exercising prudent clinical
judgment, would use with a patient to prevent,
evaluate, diagnose or treat an Illness, injury, disease
or its symptoms. These Services must:
A state licensed Doctor of Medicine and Surgery
(M.D.) or Doctor of Osteopathy (D.O.).
A mental health condition that includes developmental
delay, developmental disability or mental retardation.
This Plan covers professional Services from the
following providers as if they were provided by a
Physician as defined above:
 Agree with generally accepted standards of
medical practice
 Certified Nurse Practitioner
 Be clinically appropriate in type, frequency, extent,
site and duration and must also be considered
effective for the patient’s Illness, injury or disease
 Chiropractor (D.C.)
 Dentist (D.D.S. or D.M.D.)
 Not be mostly for the convenience of the patient,
Physician, or other health care provider. They do
not cost more than another service or series of
 Denturist
 Naturopathic Physician (N.D.)
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 Obstetrical and Gynecology (OB/GYN)
Services
 Oral Surgeon
Services are procedures, surgeries, consultations,
advice, diagnosis, referrals, treatment, supplies,
drugs, devices or technologies.
 Optometrist (O.D.)
 Physical Therapist (P.T.)
 Podiatrist (D.P.M.)
Skilled Care
 Psychologist (Ph.D.)
Medical care ordered by a Physician and requiring the
knowledge and training of a licensed registered nurse.
Also included in this definition are qualified
practitioners, professionally licensed by the
appropriate state agency to diagnose or treat
accidental injury or illness and who provides Covered
Services within the scope of that license. Not all
Services that they provide are Covered Services.
Please refer to the Covered Services and Exclusions
sections of this contract for additional information.
Skilled Nursing Facility
A medical facility licensed by the state to provide
nursing Services that require the direction of a
Physician and nursing supervised by a registered
nurse, and that is approved by Medicare or would
qualify for Medicare approval if so requested.
Small Employer
Plan
An employer, including a person, firm, corporation,
partnership or association actively engaged in
business that, on at least 50% of its working days
during the preceding year employed no more than 150 Employees (those with a normal work week of 17.5
or more hours) and no fewer than one (1) Employee,
the majority of whom are employed within Oregon
state.
The benefits, terms, and limitations stated in this
contract.
Premium
The monthly rates set by Us as consideration for the
benefits offered in this Plan.
Prescription Drug
Drugs and medications that by law require a
prescription. This includes biological used in
chemotherapy to treat cancer. It also includes
biological used to treat people with HIV or AIDS.
According to the Federal Food, Drug and Cosmetic
Act, as amended, the label on a Prescription Drug
must have the statement on it: “Caution: Federal law
prohibits dispensing without a prescription.”
Sound Natural Tooth
Prior Authorization
 Is not more susceptible to injury than a whole
natural tooth
Sound Natural Tooth means a tooth that:
 Is organic and formed by the natural development
of the body (not manufactured)
 Has not been extensively restored
 Has not become extensively decayed or involved in
periodontal disease
Prior Authorization means a determination by an
insurer prior to provision of Services that the insurer
will provide reimbursement for the Services. Prior
Authorization does not include referral approval for
evaluation and management Services between
providers.
Specialists
Specialist means a Physician who focuses on a
specific area of medicine or a group of patients to
diagnose, manage, prevent or treat certain types of
symptoms and conditions.
Reconstructive Surgery
Spouse
Reconstructive Surgery is surgery:
Spouse means an individual who is married to or a
registered Domestic Partner (as defined by Oregon
statute) of the employee.
 Which restores functionality and features damaged
as a result of Accidental Injury or Illness
 To correct a congenital deformity or anomaly.
Congenital anomaly means a marked difference
from the normal structure of a body part that is
physically evident at birth.
Tobacco Use
Tobacco use means the use of tobacco on average of
four or more times per week within no longer than the
past six months. This includes all tobacco products,
except that tobacco use does not include religious or
ceremonial use of tobacco.
Service Area
Service Area means the state of Oregon.
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Urgent Care
Treatment of unscheduled, drop-in patients who have
minor Illnesses and injuries. These Illnesses or
injuries need treatment right away but they are not
life-threatening. Examples are high fevers, minor
sprains and cuts, and ear, nose and throat infections.
Urgent Care is provided at a medical facility that is
open to the public and has extended hours.
We, Us and Our
LifeWise Health Plan of Oregon
You and Your
A Member enrolled in this Plan
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where to send claims
CUSTOMER SERVICE:
800-596-3440
MAIL YOUR CLAIMS TO:
LifeWise
P.O. Box 7709
Bend, OR 97708-7709
www.lifewiseor.com