How Providers Affect Your Costs for more information. You also have access to facilities, emergency rooms, surgical centers, equipment vendors or pharmacies providing covered services throughout the United States and wherever you may travel.
How Providers Affect Your Costs. No charge first 2 visits per calendar year, then $30 copay, deductible waived Not covered Telehealth services. See Telehealth Virtual Care Services. $15 copay, deductible waived Not covered Office visit for women’s health. For example gynecologist. $30 copay, deductible waived Not covered All other office and clinic visits (including non-preventive nutritional therapy) $50 copay, deductible waived Not covered Home Based Chronic Care Evaluation and management services of No charge Not covered YOUR COSTS OF THE ALLOWED AMOUNT IN-NETWORK PROVIDERS OUT-OF-NETWORK PROVIDERS multiple chronic conditions provided by a doctor or nurse practitioner in your place of residence. Some services, such as x-rays, lab, and durable medical supplies charges may have additional cost to you. See those covered services for details. Preventive Care Exams, screenings and immunizations (including seasonal immunizations in a provider’s office) are limited in how often you can get them based on your age and gender Seasonal and travel immunizations (pharmacy, mass immunizer, travel clinic and county health department) Health education, preventive nutritional therapy for diseases such as diabetes, and nicotine dependency treatment No charge No charge No charge Not covered No charge Not covered Contraception Management and Sterilization No charge Not covered Diagnostic Lab, X-ray and Imaging Preventive care screening and tests No charge Not covered Basic diagnostic lab, x-ray and imaging Deductible, then 20% coinsurance Not covered Major diagnostic x-ray and imaging Deductible, then 20% coinsurance Not covered Pediatric Care Limited to members under age 19 Pediatric Vision Services Routine exams limited to once per year $30 copay, deductible waived $30 copay, deductible waived One pair glasses, frames and lenses limited to once per year. Lens features limited to polycarbonate lenses and scratch resistant coating. No charge No charge One pair of contacts or a 12-month supply of contacts per calendar year, instead of glasses (lenses and frames) No charge No charge Contact lenses and glasses required for medical reasons No charge No charge One comprehensive low vision evaluation and four follow up visits in a five calendar year period No charge No charge Low vision devices, high powered spectacles, magnifiers and telescopes when medically necessary No charge No charge Prescriptions– Retail Pharmacy Up to a 30-day supply. Must use contracted pharmacy. Prevent...
How Providers Affect Your Costs. In-Network Providers This dental plan utilizes the Dental Value network providers. This plan provides you benefits for covered services from providers of your choice. You have access to one of the many providers included in our Dental Value network. This plan makes available to you a sufficient number and types of providers to give you access to all covered services in compliance with applicable Washington state regulations governing access to providers. Our provider network includes dentists and a variety of other types of providers. A list of in-network providers is available in our Dental Value provider directory. These providers are listed by member system, geographical area, specialty and in alphabetical order to help you select a provider that is right for you. We update this directory regularly, but it is subject to change. We suggest that you call us for current information and to verify that your provider, their office location, or provider group is included in the Dental Value network before you receive services. The Dental Value provider network directories are available any time on our website at xxxxxxxx.xxx. You may also request a copy of this directory by calling customer service at the number located in Contact Information or on your LifeWise ID card. As a LifeWise member, you have access to a nationwide network of Dental Value providers who can provide preventive and specialty dental care services. When you receive services from Dental Value providers, your claims will be submitted directly to us and available benefits will be paid directly to the dental care provider. Dental Value providers agree to accept our "allowed amount" as payment in full. See the Definitions section in this booklet. You're responsible only for the calendar year deductible, coinsurance, amounts that are in excess of stated benefit maximums, and charges for non-covered services.
How Providers Affect Your Costs. MEDICAL SERVICES This plan is a Preferred Provider plan (PPO). This means that your plan provides you benefits for covered services from providers of your choice. It also gives you access to the Heritage Signature provider network and to networks in other states with which we have arranged to provide covered services to you. Hospitals, physicians and other providers in these networks are called "in-network providers." A list of in-network providers is available in our LifeWise Connect 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. The provider directory also shows which providers you can select as your PCP. You can receive the lower copayment amount on primary care office visit copays by selecting a provider as your Primary Care Provider (PCP) and telling us the name of the PCP any time prior to an office visit. If you are having difficulty choosing an available PCP, contact us and we will assign a PCP to you. See Primary Care Office Visits for more information. We update this directory regularly, but it is subject to change. We suggest that you call us for current information and to verify that your provider and their office location or provider group are included in the LifeWise Connect network before you receive services. Our provider directory is available any time on our website at xxxxxxxxxx.xxx. You may also request a copy of this directory by calling Customer Service at the number located on the back cover or on your LifeWise ID card. In-Network Providers In-network providers provide medical services for a negotiated fee. This fee is the allowed amount for in-network providers. When you receive covered services from an in-network provider, your medical bills will be reimbursed at a higher percentage (the in-network provider benefit level). In-network providers will not charge more than the allowed amount. This means that your portion of the charges for covered services will be lower. If a covered service is not available from an in-network provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. See Prior Authorization for details. Out-of-Network Providers Out-of-network providers are providers that are not part of your network. Your bills will be reimbursed at the lower percentage (the out-of-network benefit level) and the provider may bill you for charges above the allowed am...
