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WiseSavings HSA
Premiums | WiseSavings
HSA Benefits
LifeWise WiseSavings HSA Benefits
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WiseSavings (Individual) |
WiseSavings (Family)2 |
| PCY = Per Calendar Year |
Preferred |
Non-Preferred |
Preferred |
Non-Preferred |
| Annual Deductible PCY (choose
one) |
$1,840/$3,000
Per Individual
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$3,680/$6,000
Per Family2
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| Coinsurance (what you pay) |
20% |
40% |
20% |
40% |
| Annual Coinsurance Maximum |
$2,500/$1,750 |
Unlimited |
$5,000/$3,500 |
Unlimited |
Covered Services (calendar year maximum $2 million) |
Office Visits
includes Urgent Care & Naturopathy |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 20% |
Deductible, then 40% |
| Preventive Exams |
Covered in Full1 |
Not covered |
Covered in Full1 |
Not covered |
Preventive Screenings3
includes mammograms |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 20% |
Deductible, then 40% |
| Immunizations |
Covered in Full1 |
Not covered |
Covered in Full1 |
Not covered |
| Pharmacy - Retail (30-day supply) |
Not covered;
pharmacy discount program available. |
Not covered;
pharmacy discount program available. |
| Pharmacy - Mail Order (90-day supply) |
| Outpatient Diagnostic X-rays and Lab Services |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 20% |
Deductible, then 40% |
| Emergency Room Care |
Deductible, then 20% |
Deductible, then 20% |
Deductible, then 20% |
Deductible, then 20% |
Ambulance Transportation
Air: unlimited; Ground: $5,000 PCY limit |
| Inpatient & Outpatient Facility Care |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 20% |
Deductible, then 40% |
Rehabilitation
(Outpatient: 15 visits PCY only Inpatient: 10 days PCY only)
Physical, occupational, massage & speech therapy; cardiac &
pulmonary rehabilitation |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 20% |
Deductible, then 40% |
| Durable Medical Equipment and Prosthetics |
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| Maternity Care |
Not Covered |
Not Covered |
| Vision - Routine Exam |
Not Covered |
Not Covered |
| Vision - Hardware |
| Mental Health–Outpatient |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 20% |
Deductible, then 40% |
| Mental Health–Inpatient |
| The following are included in your LifeWise plan: |
Preventive Exams – covered in full within network3
- Routine physicals and physicals for school, sports and employment
- Women’s or men’s
annual exams
- Well-baby and newborn exams
- Preventive immunizations (includes HPV vaccine)
Preventive Screenings – covered in full within network3
- Cancer Screenings: Cervical (PAP), prostate (PSA), mammograms and colonoscopies.
- Infectious Disease Screenings: Chlamydia
antibody and hepatitis antigen screenings
- Metabolic, Nutrition and Endocrine Screenings: Glucose testing (blood sugar) and anemia (iron deficiency) screenings
- Heart and Vascular Disease
Screenings: Lipid panel/lipoprotein/high cholesterol screenings and high blood pressure testing
- Musculoskeletal Disorder Screening: Bone density screening (osteoporosis)
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- Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance.
- Family = Individual plus one or more family members. Services for family members covered under the same HSA-qualified plan are applied to the family deductible. The family deductible must be
met before services are covered for any enrolled family members.
- A full list of preventive screenings, tests and other preventive services, is available on lifewisewa.com. You can receive these preventive services covered in full if you use preferred providers
and are within the frequency, age, risk and gender guidelines outlined in the list..
- The Select Drug List helps reduce prescription drug costs by excluding select medications that have over-the-counter (OTC) alternatives available and brand name drugs that have generics available.
Excluded drug classes because of ample OTC availability include cough and cold, antihistamines & heartburn/acid reflux medications.
Note: Deductible, coinsurance and copay represent what you pay.
Benefits apply after calendar year deductible is met, unless otherwise noted as “Deductible Waived,” “Copay” or “Covered in Full.”
All coinsurance amounts are based on allowable charges. Balance billing may apply if a provider is not contracted with LifeWise Health Plan of Washington.
Please note that this is a general summary. Your individual health plan contract will describe the actual terms, conditions and exclusions of coverage.
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Asuris NW Health 
