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LifeWise HealthPlans of Washington: Exclusions & Limitations

Benefit plans typically have exclusions and limitations— what the plans do not cover.  The following are general exclusions and limitations for the benefit plans described in this Overview of Coverage.  

Please note that this is not a contract. The complete terms of coverage are determined by the contract.

Am I eligible?
You must be a resident of the state of Washington and not eligible for Medicare to apply. To review additional eligibility requirements, please refer to the application.

What is not covered

Benefits are not provided for treatment, surgery, services, drugs or supplies for any of the following:

• Chemical dependency or tobacco addiction
• Cosmetic or reconstructive surgery (except as specifically provided)
• Dental services (except as specifically provided)
• Experimental or investigative services
• Hearing examinations or hardware
• Infertility
• Learning disorders
• Neurodopmental disabilities
• Obesity/morbid obesity, including surgery, drugs, foods and exercise programs.
• Orthognathic surgery (except when repairing a dependent child’s congenital abnormality)
• Orthotics, except for treatment of diabetes
• Over-the-counter or non-prescription drugs
• Services in excess of specified benefit maximums
• Services payable by other types of insurance coverage
• Services received when you are not covered by this program
• Sexual dysfunction
• Sterilization (on WiseChoices Prime and WiseEssentials Rx only) and sterilization reversal
• Temporomandibular joint (TMJ) disorder

Waiting Periods
There is a 9-month waiting period for pre-existing conditions (not applicable to individuals under the age of 19). There is a 12-month waiting period for coverage of transplants for all eligible members. Waiting periods may be reduced or waived for prior health plan coverage.

• Maternity/obstetrical care is not covered under WiseSimplicity, WiseEssentials Rx, WiseEssentials Copay and WiseSavings plans.
• Prescriptions are not covered under WiseSimplicity, WiseEssentials Copay and WiseSavings plans.
• Routine Vision Care is not covered under WiseSimplicity, WiseEssentials Rx, WisEssentials Copay and WiseSavings plans.
• Allergy testing and injections are not covered under the WiseSimplicity, WiseEssentials Rx and WiseEssentials Copay plans.
• Disposable diabetic supplies are not covered under the WiseSimplicity, WisEssentials Copay and WiseSavings plans.