anderson perry & associates, inc. - lifewise · passport lifewise health plan of oregon lwo lg...

Anderson Perry & Associates, Inc.

Passport 4000337

Passport LifeWise Health Plan of Oregon LWO LG 01-2016 Anderson Perry & Associates, Inc., 4000337

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

LifeWise Health Plan of Oregon P O Box 7709 Bend, OR 97708-7709

1-800-596-3440

TDD number for the hearing impaired 1-800-842-5357

Portland

LifeWise Health Plan of Oregon 2020 SW Fourth Avenue, Suite 1000 Portland, OR 97201

(503) 295-6707

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: Anderson Perry & Associates, Inc.

Effective Date: January 1, 2016

Group Number: 4000337

Plan: Passport

Certificate Form Number: LWO LG 01-2016


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.

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 LifeWise Health Plan of Oregon – Our Web site address, phone numbers, mailing

addresses and other contact information conveniently located inside the front cover • Summary of Your Costs – Lists your costs for covered services • Important Plan Information – Describes Deductibles, out-of-pocket Maximum, and allowed amount and

provides details about how these provisions apply to Your Plan. • 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 • 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 • Continuation of 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


TABLE OF CONTENTS SUMMARY OF YOUR COSTS ..................................................................................................................... 1

IMPORTANT PLAN INFORMATION ............................................................................................................ 6

Deductible ............................................................................................................................................... 6

Out-of-Pocket Maximum ......................................................................................................................... 6

Allowed Amount ...................................................................................................................................... 6

HOW PROVIDERS AFFECT YOUR COSTS ............................................................................................... 6

Care Outside the Service Area ............................................................................................................... 7

PRIOR AUTHORIZATION AND EMERGENCY ADMISSION NOTIFICATION ........................................... 7

UTILIZATION REVIEW ................................................................................................................................. 9

PERSONAL HEALTH SUPPORT PROGRAMS .......................................................................................... 9

CONTINUITY OF CARE................................................................................................................................ 9

COVERED SERVICES ................................................................................................................................ 10

Common Medical Services ................................................................................................................... 11

Prescription Drugs ................................................................................................................................. 12

Other Covered Services ........................................................................................................................ 21

EXCLUSIONS ............................................................................................................................................. 25

OTHER COVERAGE................................................................................................................................... 30

Coordination of Benefits ........................................................................................................................ 30

Third Party Liability (Subrogation) ......................................................................................................... 32

SENDING US A CLAIM .............................................................................................................................. 33

GRIEVANCE AND APPEALS .................................................................................................................... 35

ELIGIBILITY AND ENROLLMENT ............................................................................................................. 37

Effective Date of Coverage ................................................................................................................... 39

Enrollment Provisions for Late and Special Enrollees .......................................................................... 39

TERMINATION OF COVERAGE ................................................................................................................ 41

When Coverage Ends ........................................................................................................................... 41

CONTINUATION OF COVERAGE ............................................................................................................. 42

OTHER PLAN INFORMATION ................................................................................................................... 43

DEFINITIONS .............................................................................................................................................. 46

1 Passport LifeWise Health Plan of Oregon LWO LG 01-2016 SYC Anderson Perry & Associates, Inc., 4000337

SUMMARY OF YOUR COSTS This is a Summary of Your Costs for Covered Services. Some Services require Prior Authorization.

Your costs are subject to all of the following: • The allowed amount. This is the most this Plan allows for a Covered Service. • The Copay. This is an amount You pay at the time You get Services. • 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:

Year Deductibles: • Individual $2,000 per Member • Family $4,000 per Family

• The out-of-pocket maximum. This is the most You pay each Year for Services.

Out-of-Pocket Maximum: • Individual $5,000 per Member • Family $10,000 per Family

• Prior authorization. Some Services must be authorized by Us in writing 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.

COVERED SERVICES YOUR COSTS

(of the allowed amount)

IN-NETWORK PROVIDERS

OUT-OF-NETWORK PROVIDERS

COMMON MEDICAL SERVICES

Office and Clinic Visits $30 Copay 40%

• Facility charges You may have additional costs for things such as x-rays, lab and therapeutic injections. See those Covered Services for details.

20% 40%

Preventive Care Limited to how often You can get them based on Your age and if You are male or female.

• 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 40%

• Pregnant women’s Services, diabetic supplies, electric breast pumps and supplies

$0, deductible waived 40%

• Men’s prostate screening, including PSA $0, deductible waived 40% • Colon cancer screening, outpatient lab and

radiology for preventive screening and tests $0, deductible waived 40%

• Flu shots, flu mist, immunizations for shingles, pneumonia and Pertussis at a pharmacy

$0, deductible waived 0%, deductible waived






COMMON MEDICAL SERVICES • Contraceptive management, elective sterilization,

tubal ligation and vasectomy $0, deductible waived 40%

• 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 $0, deductible waived • Diabetes health education $0, deductible waived $0, deductible waived • Nutritional therapy for diabetes $0, deductible waived 40%

• Nutritional therapy $0, deductible waived 40%

Diagnostic X-ray, Lab and Imaging X-ray and lab, including MRI, MRA, PET and CT Scans

20%, deductible waived 40%

Outpatient Prescription Drugs

Retail Pharmacy

Limited up to a 90-day supply. Some contraceptives maybe allowed up to a 12 month supply. You pay one Copay for each 30 day supply.

• Formulary Preventive drugs, limited to prescribed drugs required by health care reform and insulin during pregnancy


• Formulary Nicotine cessation drugs, oral generic and single source brand name contraceptive drugs and devices


• Formulary Generic $10 Copay Not covered • Formulary Preferred Brand Name $35 Copay Not covered • Formulary Non-Preferred Brand Name $50 Copay Not covered

Prescriptions By Mail Limited up to a 90-day supply. Some contraceptives may be allowed up to a 12 month supply. You pay one Copay for each 90 day supply.

• Formulary Preventive drugs, limited to prescribed drugs required by health care reform and insulin during pregnancy


• Formulary Nicotine cessation drugs, oral generic and single source brand name contraceptive drugs and devices


• Formulary Generic $25 Copay Not covered • Formulary Preferred Brand Name $87 Copay Not covered • Formulary Non-Preferred Brand Name $125 Copay Not covered

Retail Specialty Pharmacy Specialty pharmacy limited to a 30-day supply

Subject to the Retail pharmacy cost shares under the drug categories listed above

Not covered






COMMON MEDICAL SERVICES

If You request a brand name drug at a retail pharmacy or by mail when a generic is available, You will be responsible for the Copayment and the difference in cost between the brand name and the generic equivalent.

Outpatient Surgery Services Hospitals, ambulatory surgery center, doctor’s office and the professional services

20% 40%

Emergency Room Includes emergency room and Hospital Urgent Care facilities.

$125 Copay, then 20% $125 Copay, then 20%

The Copay is waived if You are admitted as an Inpatient through the emergency room.

Emergency Room Physician 20% 20%

Emergency Ambulance Services Emergency air and ground ambulance Services

20% 20%

Urgent Care Centers Includes facility and professional Services You may have additional costs for things such as x-rays, lab and therapeutic injections. See those Covered Services for details.

$30 Copay 40%

Urgent Care Centers, facility based You may have additional costs for things such as x-rays, lab and therapeutic injections. See those Covered Services for details.

20% 40%

Hospital Services 20% 40%

Mental Health, Behavioral Health and Substance Abuse

• Office visits $30 Copay 40% • Outpatient facility Services 20%, deductible waived 40% • Inpatient Hospital, partial hospitalization, residential

facilities 20% 40%

Maternity and Newborn Care Prenatal care, delivery and postnatal care provided by Your attending physician.

20% 40%

Home Health Care Limited to 130-days per Year

20% 40%






COMMON MEDICAL SERVICES Hospice Care Limited to a 6-month maximum. Respite care is limited to 5 days.

20% 40%

Rehabilitation Therapy Limited to a combined 20 Outpatient visits and a combined 30 inpatient days per Year. Limits are not applicable to mental health Services. See Mental Health benefit for these Services.

• Outpatient office Services 20% 40% • Inpatient facility Services 20% 40% • Outpatient facility Services 20% 40%

Neurodevelopmental Therapy The Neurodevelopmental Therapy outpatient visits are combined with the Rehabilitation outpatient therapy benefit.

See Outpatient Rehabilitation Therapy

See Outpatient Rehabilitation Therapy

Skilled Nursing Facility Limited to 100 days per Year 20% 40% Home Medical Equipment (HME), Supplies, Devices, Prosthetics and Orthotics Foot orthotics for conditions other than diabetes are limited to $200 per Year.

20% 40%

OTHER COVERED SERVICES

Allergy Testing and Treatment 20%, deductible waived 40%

Alternative Care Acupuncture, Chiropractic and naturopathic Services, combined limit of $1500 per Year.

$30 Copay Not covered

Biofeedback $800 per Year, this limit does not apply to Mental Health Services

20% 40%

Chemotherapy and Radiation Therapy

• Chemotherapy includes infusion, injectable drugs 20% 40%

• Prescribed oral chemotherapy drugs 20%, deductible waived 40%

Clinical Trials $30 Copay 40%

Community Wellness and Safety Programs Limited to $250 per year.

0%, deductible waived 0%, deductible waived

Craniofacial Anomalies $30 Copay 40%

Dental Accidents – Outpatient Visits Limited to $500 per Year

0%, deductible waived 0%, deductible waived

Dental Anesthesia - Outpatient Limited to the following: • Members under age 7 with a disability

20% 40%






COMMON MEDICAL SERVICES • Members with a medical condition and it is not safe

to do the treatment outside a Hospital or ambulatory surgical center.

20% 40%

Dialysis Services Dialysis Services for End-Stage Renal Disease (ESRD)

20% 40%

Foot Care Routine care that is Medically Necessary for treatment of diabetes

20% 40%

Hearing 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.

20% 20%

Hearing Exam • Limited to Members under the age of 19. Limited to

a Benefit Maximum Limit of $50 per Year.

$20

$20

• Limited to Members age of 19 and older. Limited to a Benefit Maximum Limit of $50 per Year.

$20 $20

Infusion Therapy (outpatient) 20% 40%

Mastectomy and Breast Reconstruction 20% 40%

Sleep Studies - Outpatient 20% 40%

Telehealth Virtual Care Services $30 Copay 40% Telemedicine Services • Office visits $30 Copay 40% • Facility Services 20% 40%

Temporomandibular Joint Disorder (TMJ) Limited to a $1,000 per Year, up to a lifetime maximum of $5,000

$30 Copay 40%

Therapeutic Injections 20%, deductible waived 40% Transplants • Donor Covered Services

$75,000 maximum per transplant 20% Not covered

• Office Visits $30 Copay Not covered • Inpatient facility, Outpatient care and related

Services 20% Not covered

• Travel and lodging expenses per transplant up to a maximum of $7,500

0% 0%

6 Passport LifeWise Health Plan of Oregon

LWO LG 01-2016 Anderson Perry & Associates, Inc., 4000337

IMPORTANT PLAN INFORMATION DEDUCTIBLE Individual Deductible This Plan includes an individual deductible. 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.

Family Deductible This Plan limits the total deductible that must be met by all family Members on this Plan. Any amount that We count toward a Member’s individual deductible also counts toward the family deductible. When the family deductible is met, all individual deductibles are also met. This is true even if some Members did not meet their individual deductible.

If you do not satisfy Your Year deductible, Covered Services used by You during the last three (3) months of the Year that are credited to Your deductible, will also be credited to Your following Year deductible.

OUT-OF-POCKET MAXIMUM Individual Out-of-Pocket Maximum This Plan includes an individual out-of-pocket maximum for Covered Services 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.

Family Out-of-Pocket Maximum This Plan includes a family out-of-pocket maximum for Covered Services 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.

Expenses that do not apply to Your out-of-pocket maximum include: • Charges in excess of the allowed amount; • Services in excess of any Benefit Maximum Limit or

Durational Limit; • Services not covered by this Plan; • Any Covered Services as shown on the Summary

of Your Costs or on a Supplemental Benefit as not applicable to the out-of-pocket maximum;

• Prior Authorization Penalty

PRE-EXISTING CONDITION PROVISION This Plan does not have a Pre-Existing Condition Provision.

ALLOWED AMOUNT This Plan provides benefits based on the allowed amount for Covered Services. The allowed amount is described below.

Non-Emergency Services In-Network Providers

The allowed amount is the fee that LifeWise has negotiated with its in-network providers for Covered Services.

Out-of-Network Providers

The allowed amount is the lesser of the following: • The provider’s billed charge • 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.

• 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.

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 • 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, Copayments and Coinsurance, You will be responsible for charges received from Out-of-Network Providers above 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.

You Can Benefit By Designating A Primary Care Provider

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 designate a PCP at the time You enroll in this Plan. Selecting a PCP gives You a partner to help You manage Your care.

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.

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 in-network benefit level), and Our 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.

Contracted Providers Who Offer Unique Services

We have contracted with some health care systems to provide unique Services that are not available from Our in-network providers. We contract with these health care systems to provide covered Medical Services at negotiated fees. These unique Services will be processed at the in-network benefit level and You will not be balance billed for any charge over the Allowed Amount.

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 percentage (the out-of-network benefit level) 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.

How to Select a LifeWise In-Network Provider

A list of Our out-of-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. 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 LifeWise network before You get Services.

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 inside the front of this Benefit Booklet or on Your LifeWise ID Card.

Availability of Covered Services

Not all Covered Services are available from all in-network providers and providers may be reimbursed at different benefit levels. Your Summary of Your Cost lists the benefits that are available from in-network providers and out-of-network providers and the benefit level allowed for the Covered Services they provide.

Your level of benefits depends on the provider who provides You with Covered Services. You will always get the highest level of benefits and have lowest out-of-pocket costs when You receive Covered Services from an in-network provider.

The Covered Services listed below are only available from an in-network provider as shown on the Summary of Your Costs. • Preventive Care • Transplants • Nicotine Dependency Programs • Other Health Education Services • Alternative Health Care Services

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.

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 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 • When You want to receive the higher benefit level

for Services You received from an out-of-network provider

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.

Prior Authorization Penalty 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, You will be subject to a penalty. The penalty is 50% of the allowed amount for Covered Services, up to a maximum of $1,500. Your costs for this penalty do not count toward Your Plan deductibles and out-of-pocket maximum.

RESPONDING TO PRIOR AUTHORIZATIONS 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. Expedited reviews are responded to as soon as possible, but no later than 48 hours after We have been given all the necessary information to make a decision. We will provide Our decision in writing. 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 listed below are not subject to a Prior Authorization penalty: • Emergency hospital admissions. See Emergency

Admission Notification described below. • Prescription Drugs. See Prior Authorization for

Prescription Drugs described below. • Non-Emergency Services from out-of-network

providers. See Non-Emergency Services From Out-of-Network Providers described below.

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.

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 may also view Our list of prescription drugs that require prior authorization through the Member portal on Our website lifewiseor.com. Once You “Sign in”, please go to “My Plan Information,” then select the “Pharmacy” tab and finally You’ll select “View drugs that require Prior Authorization”.

You can also find the Prior Authorization form that Your physician can complete 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.

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.



Non-Emergency Services From Out-of-Network Providers

There may be times when You want to see an out-of-network 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: • A statement that the out-of-network provider has

unique skills that are Medically Necessary for Your care

• You cannot get the same care from an in-network provider

• 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.

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.

Emergency Admission Notification The following Services do not need authorization, but they have separate requirements: • Emergency hospital admissions, including

admissions for drug or alcohol detoxification. They do not require prior authorization, but You must notify Us as soon as reasonably possible.

• If You are admitted to an out-of-network hospital due to an Emergency Medical Condition, those Services will always be covered under Your in-network 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.

• 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.

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:

LifeWise

Utilization Review

P.O. Box 7709

Bend, OR 97708

1-800-722-3372

Fax 800-843-1114

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.

PERSONAL HEALTH SUPPORT PROGRAMS LifeWise offers participation in our Personal Health Support Services to help members with such things as managing complex medical conditions, a recent surgery, or admission to a hospital. Our services include: • Helping to overcome barriers to health

improvement or following providers’ treatment plan • Coordinating care services including access • Helping to understand the health plan’s coverage • Finding community resources

Participation is voluntary. To learn more about the Personal Health Support program, contact Customer Service at the phone number listed on the back of your LifeWise ID card.

CONTINUITY OF CARE Continuity of Care means that You are in an active treatment plan and receiving Covered Services from an In-network provider while insured under this Plan



and the In-network provider ends his/her contract with LifeWise. This means Your provider becomes an out-of-network provider.

We will notify You, if it is reasonably known to Us that You are under an active treatment plan with an In-network provider, no later than the 10th day after the date on which Your in-network provider’s contract with LifeWise terminates. If LifeWise learns after the termination date of Your in-network provider’s contract with LifeWise that You were in an active treatment plan, We will notify You no later than the 10th day after We become aware of this fact. In order to obtain Continuity of Care, You must request Continuity of Care from Us.

If You would like Us to consider Your request to continue receiving services at the In-network provider benefit level, please call or send Your request to:

LifeWise

Care Management

Utilization Review

P.O. Box 7709

Bend, Oregon 97708

1-800-722-3372

Fax 1-800-843-1114

Continuity of Care is subject to specific regulatory requirements. You may be eligible to continue Your treatment plan with this provider for a limited period of time at the In-network provider’s benefit level if the treatment is Medically Necessary and You and this provider agree that it is desirable to maintain Continuity of Care.

We will not provide continuity of care when You discontinue Your coverage or when the contractual relationship between the individual provider and Us terminates and the 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; or • Terminates the contractual relationship in

accordance with provisions of contract relating to quality of care and exhausts his/her contractual appeal rights.

Duration of Continuity Of Care

If You are eligible for continuity of care, You will receive Continuity of Care until the earlier of: • The day following the date You complete the active

course of treatment entitling You to Continuity of Care; or

• The 120th day after We notify You that Our contractual relationship with the In-network provider terminated; or the date on which We receive or approve Your request for Continuity of Care, whichever is earlier.

• 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: • The 45th day after the birth; or • As long as You continue under an active course

of treatment, but no later than the 120th day after We notify You of the termination of Our contractual relationship with the in-network provider, or the date on which We receive or approve Your request for Continuity of Care, whichever is earlier.

When Continuity of Care terminates, You may continue to receive Services from this same provider, however, We will pay for Covered Services at the out-of-network provider benefit level subject to the allowed amount. Please refer to How Providers Affect Your Costs With LifeWise In-network Providers for information.

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 as outlined in Your Plan.

COVERED SERVICES This section describes 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: • 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

setting. This Plan covers Inpatient care only when You cannot get the Services in a less intensive setting.

• The Service is not excluded • The provider is working within the scope of their

license or certification



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: • Copays • Deductibles • Coinsurance • Benefit limits • 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.

• 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 lifewiseor.com or by calling Customer Service.

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 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.

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 Admission Notification section for details.

PREVENTIVE CARE 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).

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/ uspsabrecs.htm and www.hrsa.gov/womensguidelines. This list may be changed as required by law.

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. • Mammograms. See Diagnostic X-ray, Lab, and

Imaging for mammograms needed because of a medical condition.

• Pregnant women’s Services such as breast feeding counseling before and after delivery and maternity diagnostic screening, diabetic supplies from conception to six weeks postpartum

• 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. The cost of the rental cannot be more than the purchase price.

• Prostate cancer screening. Includes digital rectal exams and prostate-specific antigen (PSA) tests.

• Colon cancer screening. Includes exams, colonoscopy, sigmoidoscopy, double contrast barium enemas, removal of polyps in the colon and fecal occult blood tests

• Outpatient lab and radiology for preventive screening and tests

• 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.

• Contraceptive management. Includes exams, treatment You get at Your provider’s office, emergency contraceptives, supplies and devices. Tubal ligation and vasectomy are also covered. See Prescription Drugs for prescribed oral contraceptives and devices.



• Health education and training for covered conditions such as diabetes, high cholesterol and obesity. Includes Outpatient self-management programs, training, classes and instruction.

• 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 nicotine dependency 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.

• Fall prevention age 65 and older

This benefit does not cover: • Charges for Services that do not meet federal

guidelines. This includes Services provided more often that the guidelines allow.

• Oral prescription contraceptives dispensed and billed by Your provider or a Hospital

• Over the counter (OTC) drugs, contraceptive foams, jellies, sponges or condoms, unless prescribed by a physician. See Prescription Drugs for prescribed oral contraceptives and devices.

• Gym memberships or exercise classes and programs

• Inpatient newborn care 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.

• Lab and Pathology Services for colonoscopy or sigmoidoscopy. See Diagnostic X-ray, Lab and Imaging.

• Physical exams for basic life or disability insurance • Work-related disability evaluations or medical

disability evaluations

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.

Diagnostic tests include: • Diagnostic imaging and scans like x-rays, MRIs

and EKGs • Mammograms for a medical condition • MRI and ultrasound of the breast • Men’s bone density screening for osteoporosis • Barium enema • Lab Services • Pathology tests

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.

• Diagnostic surgeries, biopsies and scope insertion procedures. These Services covered under the Outpatient Surgery Services benefit.

• Allergy tests. These Services are covered under the Allergy Testing and Treatment benefit.

PRESCRIPTION DRUGS 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.

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.

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.

Your provider may request that You get a non-formulary 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: • There is no formulary drug or alternative available • You cannot tolerate the formulary drug • The formulary drug or dose is not safe or effective

for Your condition

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.

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.”

• Off-label use of FDA-approved drugs. • Off label oral chemotherapy Prescription Drugs are

not covered under this benefit. See Chemotherapy and Radiation Therapy

• 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

• Throw-away diabetic test supplies such as test 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 • 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

• 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

• Step therapy, meaning You must try a generic drug or a specified brand name drug first

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.

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.

Preventive Drugs

Your prescription benefit includes certain Outpatient drugs as preventive drugs. This benefit includes only those drugs required by federal health care reform. Preventive drugs do not include drugs for treating an existing Illness, injury or condition.

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 lifewiseor.com.

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.

If You do not show Your LifeWise ID Card at an in-network 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 does not cover Prescription Drugs from out-of-network pharmacies.



Prescription Drug Volume Discount Program

Your Prescription Drug benefit program includes per-claim 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: • We keep the difference and apply it to the cost of

Our operations and the Prescription Drug benefit program

• We credit the difference to premium rates for the next benefit year

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.

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 • The total units or days’ supply You got for the same

medication in the 180-day period before the last refill

Specialty Pharmacy Programs

The Specialty Pharmacy Program includes drugs that are used to treat complex or rare conditions. These drugs need special handling, storage, administration, or patient monitoring. This Plan covers these drugs 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.

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 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.

• Non-formulary generic and brand name drugs • Drugs from out-of-network pharmacies • Drugs from out-of-network specialty pharmacies • Drugs for cosmetic use such as for wrinkles • Drugs to promote or stimulate hair growth • 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

• 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.

• 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.

• Immunizations. See Preventive Care. • 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 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: • Anesthesia and postoperative care • Corneal transplants and skin grafts • Cochlear implants, including bilateral implants • Blood transfusion, including blood derivatives



• Biopsies and scope insertion procedures such as endoscopies

• Colonoscopy and sigmoidoscopy for a medical condition

• Voluntary termination of pregnancy • 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.

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.

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 Transplants for details. • Vasectomy. See Preventive Care for these

Covered Services.

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.

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.

Covered Services include the following: • The emergency room • Emergency room Physician as shown on the

Summary of Your Costs • Services used for Emergency Medical Screening

Exams and for stabilizing an Emergency Medical

Condition • Outpatient diagnostic tests billed by the emergency

room that You get with other emergency room Services

• Hospital based urgent care facilities

Emergency Services benefits are covered at the in-network 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.

This benefit does not cover the inappropriate (non-emergency) 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.

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 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.

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.

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.

Services You get in an Urgent Care center that are billed by the Hospital or emergency room are covered under the Emergency Services benefits.



HOSPITAL SERVICES 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.

Inpatient Care Covered Services include: • Room and board, general duty nursing and special

diets • Doctor Services and visits • Use of an intensive care or special care units • Operating rooms, surgical supplies, anesthesia,

drugs, blood, dressing, equipment and oxygen • X-ray, lab and testing

Anesthesia for Dental Services Outpatient Care Covered Services include: • Operating rooms, procedure rooms and recovery

rooms • 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

done with other Hospital 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: • 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

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

• Any days of Inpatient care beyond what is Medically Necessary to treat the condition

• Dental treatment or procedures

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 state-approved 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.

Medically Necessary reconstructive surgery services due to a Mental Health condition, listed in the current Diagnostic and Statistical Manual (DSM), are Covered under the Outpatient Surgery Services benefit or Hospital Services section for inpatient Care.

You must get Prior Authorization from Us before You get treatment. See the Prior Authorization and Emergency Admission Notification section for details.

Mental Health (Behavioral Health) Care 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, speech, habilitative and occupational therapy provided for treatment of a mental condition including autism spectrum disorders.

• Individual, family or group therapy • Lab and testing • Take-home drugs You get in a facility

In this benefit, “Outpatient visit” means a clinical treatment session with a mental health provider.

Applied Behavioral Analysis (ABA) Therapy This Plan covers ABA therapy. The Member must be diagnosed with one of the following disorders: • Autistic disorder • Autism spectrum disorder • Asperger’s disorder • Childhood disintegrative disorder • Pervasive Development Disorder • Rhett’s disorder

Services must be provided by: • A Physician (MD or DO) who is a psychiatrist,

developmental pediatrician or pediatric neurologist • A state-licensed psychiatric nurse practitioner (NP),

advanced nurse practitioner (ANP) or advanced registered nurse practitioner (ARNP)

• A state-licensed masters-level mental health clinician (such as licensed clinical social worker,



licensed marriage and family counselor, licensed mental health counselor)

• A state-licensed occupational or speech therapist when providing ABA therapy

• A state-licensed psychologist • Licensed Community Mental Health or Behavioral

Health agency that is also state certified for ABA therapy

• Board-Certified Behavioral Analyst (BCBA), licensed in states with behavioral analyst licensure, otherwise certified by the Behavioral Analyst Certification Board

• Therapy assistants/behavioral technicians/ paraprofessionals; when Services are supervised and billed by a licensed provider or BCBA

• This Plan covers all of the following Services: • 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

• Initial evaluation/assessment when performed by a licensed provider or BCBA

• Treatment review and planning when performed by a licensed provider or BCBA

• Communication/coordination with other providers or school personnel when performed by a licensed provider or BCBA

• Delivery of ABA covered Services for an individual may be managed by a BCBA or licensed provider who is called a “program manager”.

This benefit does not cover: • Prescription Drugs. These are covered under the

Prescription Drugs benefit. • Treatment of sexual dysfunctions, of organic origin,

including impotence and decreased libido. This exclusion does not apply to sexual dysfunction diagnoses listed in the Diagnostic and Statistical Manual (DSM).

• Institutional care, except that Services are covered when provided for an Illness or injury treated in an acute care Hospital

• Dementia • EEG biofeedback or neurofeedback • Family and marriage counseling or therapy, except

when it is Medically Necessary to treat Your mental condition

• Therapeutic or group homes, foster homes, nursing homes boarding homes or schools and child welfare facilities

• Outward bound, wilderness, camping or tall ship

programs or activities • 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.

• Support groups such as Alanon or Alcoholics Anonymous

• Services that are not Medically Necessary. • Sober living homes, such as halfway houses • Addiction to foods • Caffeine dependence • Training of therapy assistants/behavioral

technicians/paraprofessionals (as distinct from supervision)

• 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

• 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

• Functioning as an educational or other aide for the member/identified patient in school

• Provision of services that are part of an 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

• Provider travel time • Babysitting • Respite for parents/family members • Provider residing in the member’s home and

functioning as line-in help (such as an au-pair role) • Peer-mediated groups or interventions • Training or classes for groups of parents of

different patients • Hippotherapy/equestrian therapy • Pet therapy



• Auditory Integration Therapy (as part of ABA therapy)

• Sensory Integration Therapy (as part of ABA therapy)

• Any other activity that is not considered to be a behavioral assessment or intervention utilizing applied behavior analysis

MATERNITY AND NEWBORN CARE 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.

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.

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.

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.

• Outpatient x-ray, lab and imaging. These Services are covered under Diagnostic X-ray, Lab and Imaging.

• Home birth Services provided by family Members or volunteers

HOME HEALTH CARE 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.

Covered Services include: • Home visits and acute nursing (short-term nursing

care for Illness or injury) by a home health agency • 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

This benefit does not cover: • Over-the-counter drugs, solutions and nutritional

supplements • Services provided to someone other than the ill or

injured Member • 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 • Custodial Care • Non-medical Services, such as housekeeping • 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.

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

• 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

• 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

• Home health aide Services for personal care, maintenance of a safe and healthy environment and general support to the goals of the plan of care

• Rehabilitation therapies provided for purposes of symptom control or to enable You to maintain activities of daily living and basic functional skills

• 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: • Over-the-counter drugs, solutions and nutritional

supplements • Services provided to someone other than the ill or

injured Member • 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 • Custodial Care, except for hospice care Services • Nonmedical Services, such as housekeeping,

dietary assistance or spiritual bereavement, legal or financial counseling

• Services that provide food, such as Meals on Wheels or advice about food

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 Cost. See the Mental Health, Behavior Health and Substance Abuse for those Services.

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.

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.

This Plan covers Inpatient rehabilitative therapy only when it meets these conditions: • You cannot get these Services in a less intensive

setting • The care is part of a written plan of treatment

prescribed by a doctor

Covered services include all of the following: • Physical, speech and occupational therapies • Chronic pain care • Massage therapy

This benefit does not cover: • Massage therapy without any other treatment • Rolfing, polarity therapy, growth and cognitive

therapies • Self-direction or seminar type treatment • Charges for day or overnight facilities for intensive

nutrition, exercise, education, relaxation and similar service

• Recreational, vocational or educational therapy • Exercise or maintenance-level programs • Social or cultural therapy • Treatment that the ill, injured or impaired Member

does not actively take part in • Gym or swim therapy • Custodial Care

NEURODEVELOPMENTAL THERAPY SERVICES Benefits for Neurodevelopmental Therapy Covered Services are provided as stated on the Summary of Benefits subject to the combined outpatient Rehabilitation Therapy Year maximum benefit. Covered Services include Medically Necessary outpatient care needed to restore and improve function, or to maintain function where significant physical deterioration would occur without the therapy.

Outpatient Care Covered Services for outpatient care include physical, speech, and occupational therapy that meet the following criteria: • The Member must not be confined in a hospital or

other medical facility; • The therapy must be part of a formal written

treatment plan prescribed by a physician; and • Services must be furnished and billed by a hospital

or rehabilitation facility approved by Us, a physician, or a physical, occupational or speech therapist



A “visit” is a session of treatment for each type of therapy. Each type of therapy accrues toward the Year benefit maximum.

SKILLED NURSING FACILITY AND CARE This Plan covers Skilled Nursing Facility Services. Covered Services include room and board for a semi-private 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.

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.


HOME MEDICAL EQUIPMENT (HME), SUPPLIES, DEVICES, PROSTHETICS AND ORTHOTICS 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.

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.

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.

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.

Medical Supplies

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).

• Cast, braces and supportive devices when used in the treatment of medical or surgical conditions in acute or convalescent stages or as immediate post-surgical care

• Medical devices surgically implanted in a body cavity to replace or aid the function of an internal organ

• 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.

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.

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

• Orthotic devices, supports or braces applied to an existing portion of the body for weak or ineffective joints or muscles

• 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

Benefits will only be provided for the initial purchase 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.

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.

This benefit does not cover: • Hypodermic needles, lancets, test strips, testing

agents and alcohol swabs. These Services are covered under the Prescription Drugs benefit.

• Supplies or equipment not primarily intended for medical use

• Special or extra-cost convenience features • Items such as exercise equipment and weights • Whirlpools, whirlpool baths, portable whirlpool

pumps, sauna baths and massage devices • Over bed tables, elevators, vision aids and

telephone alert systems • Structural modifications to Your home and/or

personal vehicle • Orthopedic appliances prescribed primarily for use

during participation of a sport, recreation or similar activity

• Penile prostheses • Routine eye care Services including eye glasses

and contact lenses • Items which are replaced due to loss or negligence • 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 Services benefit for Inpatient and Outpatient care.

• 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)

• Enuresis alarm • Compression stockings which do not require a

prescription

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.

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.

Alternative Health Care This Plan covers Outpatient alternative health care. Services must be provided by a licensed provider and must be a Covered Service (not excluded) under this Plan.

Naturopathic Services

Naturopathic Covered Services include preventive care or Medically Necessary treatment of an Illness or Accidental Injury including but not limited to: manual manipulation, physical modalities, minor office procedures, hair analysis, fingernail analysis and common diagnostic procedures consistent with naturopathic practice.

Acupuncture Services

Acupuncture Covered Services are limited to Medically Necessary acupuncture, electro-acupuncture, cupping, and moxibustion, extravasation and Gus Sha/Tui Na.

Chiropractic Services

Chiropractic Covered Services are limited to an initial evaluation visit for each diagnosis or injury, chiropractic treatment such as manipulation for neuromusculoskeletal disorders. Related diagnostic



laboratory or x-rays Services consistent with Current Procedural Terminology (CPT) guidelines are covered as Outpatient x-ray and lab Services as shown on the Summary of Your Costs.

Chiropractic Covered Services do not include Services provided for examinations, and/or treatment of strictly non-neuromusculoskeletal disorders.

This benefit does not cover: • Preventive care. See Preventive Care for Covered

Services • Massage therapy without any other treatment • Legend of non-legend drugs or medicines, except

that vitamin B-12 intramuscular shots for a vitamin B-12 deficiency are covered

Biofeedback This Plan covers Outpatient biofeedback training for an illness or injury.

Chemotherapy and Radiation Therapy This Plan covers Services for chemotherapy and radiation therapy. Covered Services include the following: • Prescribed oral anti-cancer medications used to kill

or slow the growth of cancerous cells. • Prescribed oral anti-cancer medications used for off

label use. • Services performed or ordered by Your Physician.

This benefit applies to Services You get during an office visit or at a facility.


Clinical Trials 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 X-ray, Lab and Imaging.

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.

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.

Community Wellness and Safety Programs This Plan covers programs that promote health and life choices. These programs include adult, child and infant CPR, safety, babysitting skills, back pain prevention, how to deal with stress, bike safety and parenting skills. You pay for the cost of the program and send Us proof of payment with a reimbursement form. You can get the form on Our website, lifewiseor.com. You can also call Customer Service.

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.

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.

Dental Accident 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: • Treatment is needed because of an Accidental

Injury • 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: • Extensive restoration, veneers, crowns or splints • 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

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:



• 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

• 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

This benefit does not cover:

The dental procedure

Dialysis Services This Plan covers dialysis Services You get in an office visit or at a facility. Benefits are provided for professional Services, facility charges, and any supplies, drugs or solutions used for dialysis.

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 information about Medicare enrollment, contact Medicare at 1-800-MEDICARE or log onto their web site at www.medicare.gov.

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.

Hearing Aids 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 provider. 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.

This 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

Hearing Exam Benefits are provided for hearing exams as shown on the Summary of Your Costs subject to the Benefit

Maximum Limit. Covered Services include: • Examination of the inner and exterior ear; • Observation and evaluation of hearing; • Case history and recommendations; and • Hearing testing services including the use of

calibrated equipment

Infusion Therapy (Outpatient) This Plan covers Outpatient infusion therapy Services, supplies, solutions and drugs.


Mastectomy and Breast Reconstruction 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: • 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

• Surgery and reconstruction of the other breast to produce a symmetrical appearance

• Prostheses • Complications of all stages of mastectomy,

including lymphedemas. • Inpatient care related to the mastectomy and post-

mastectomy Services

Services are provided in a manner determined by the attending Physician with the patient in accordance with state requirements and federal WHCRA 1998 requirements.

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.

Sleep Studies 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.

Please see the Prior Authorization and Emergency Admission Notification section of this Benefit Booklet for details.



Telehealth Virtual Care Services 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.

Telemedicine 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.

This Plan also covers telemedicine Services for diabetes as required by state law.

This benefit does not cover: • Get acquainted visits without physical exam or

diagnosis or therapeutic intervention

Therapeutic Injections This Plan covers therapeutic injections given at the doctor's office, including serums, needles and syringes.

Transplants 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.

Covered Transplants

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.

These are the types of transplants and reinfusion procedures that meet Our criteria for coverage: • Heart • Heart/double lung • Single lung • Double lung • Liver • Kidney • Pancreas • Pancreas with kidney

• 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.

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.

Covered Services consist of all phases of treatment: • Evaluation • Pre transplant care • Transplant and any donor Covered Services • Follow up treatment

Donor Costs

This benefit covers donor or procurement expenses for a covered transplant. Covered Services include: • Selection, removal (harvesting) and evaluation of

the donor organ, bone marrow or stem cell • Transportation of the donor organ, bone marrow or

stem cells, including the surgical and harvesting teams

• Donor acquisition costs such as testing and typing expenses

• 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.

Temporomandibular Joint (TMJ) Disorder Benefit Benefits for TMJ Disorders are provided as shown on the Summary of Your Costs. TMJ Disorders include disorders which have one or more of the following characteristics: pain in the musculature associated with the temporomandibular joint, internal derangement of the temporomandibular joint, arthritic problems with the temporomandibular joint, or an abnormal range of motion or limitation of motion on the temporomandibular joint.



Covered Services include Services that are: • Reasonable and appropriate for the treatment of a

disorder of the temporomandibular joint, under all the factual circumstances of the case;

• Effective for the control or elimination of one or more of the following, caused by a disorder of the temporomandibular joint: pain, infection, disease, difficulty in speaking, or difficulty in chewing or swallowing food; and

• Recognized as effective, according to the professional standards of good medical practice; and

• Not Experimental/Investigational or primarily for cosmetic purposes according to the criteria stated under Definition of Terms or primarily for cosmetic purposes.

EXCLUSIONS This section lists the Services that are not covered by 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:

Amounts Over the Allowed Amount

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.

Bariatric Surgery

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 Covered Services section of the contract.

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

• 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.

Comfort or Convenience

This Plan does not cover: • 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.

• 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.

• Help with meals, diets and nutrition. This includes Meals on Wheels.

Cosmetic Services

This Plan does not cover Services and supplies for Cosmetic Services, including but not limited to: • 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

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 the Mental Health, Behavioral Health and Substance Abuse headings for these Covered Services in the Covered Services section.

Counseling and Training

This Plan does not cover counseling or training, job help and outreach and social or fitness counseling.

Court-Ordered Services

Court orders Services, unless You are receiving treatment due to a conviction while driving under the influence of intoxicants. Services must be Medically Necessary.



Custodial Care

Dental Services

Dental Services including, but not limited to the care of teeth and gums, oral surgery (non-dental or dental), and all procedures involving the teeth; wisdom teeth and areas surrounding the teeth, orthodontics including casts, models, x-rays, photographs, examinations, appliances, braces, retainers and anesthesia, unless required by law, except as shown on the Summary of Your Costs and as described under Covered Services.

Also not covered are hospital Services for dental procedures except as described under Covered Services.

Developmentally Disabled Services

Services or materials of an institution for the developmentally disabled, except while in an acute care Hospital for an Accidental Injury or Illness

Donor Breast Milk

Drug Or Food Supplements

Over the counter drugs and medicines which may be lawfully obtained over the counter (“OTC”) without a prescription (except as required by federal regulation), food supplements, herbal, naturopathic or homeopathic medicines or devices, dietaries and any other non-prescription supplements whether or not prescribed or recommended by Your provider.

Education And Training Services And Supplies • Services for convenience, educational or vocational

purposes including, but not limited to, videos and books, and volunteer mutual support groups, except as required by federal regulation.

• Charges for health clubs or health spas, aerobic and strength conditioning, work-hardening programs, and all related material and products for these programs.

• Related to behavioral disorders, marriage, family or sex counseling in the absence of a Mental Health Illness.

• Related to personal growth, assertiveness training or consciousness raising, career counseling, and learning disabilities except for attention deficit/hyperactivity disorders.

• Educational or correctional services or sheltered living provided by a school or half-way house

• Educational or training programs, regardless of diagnosis or symptoms that may be present.

Emergency Transportation

Emergency medical transportation Services that are not provided by appropriately licensed providers.

Environmental Therapy

This Plan does not cover therapy to provide a changed or controlled environment.

Experimental or Investigational Services

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.

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: • Your Spouse, mother, father, child, brother or sister • Your mother, father, child, brother or sister by

marriage • Your stepmother, stepfather, stepchild, stepbrother

or stepsister • Your grandmother, grandfather, grandchild or the

Spouse of one of these people • A volunteer, except as described in Home Health

Care and Hospice Care

Family Planning

Services related to family planning, including, but not limited to contraceptive foams, jellies, sponges or condoms; and except as described under Covered Services.

Services for oral contraceptives, cervical caps and diaphragms are covered as described under the Prescription Drugs benefit.

Food Supplements

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.

Get Acquainted Visits

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, work-



hardening programs and all related material and products for these programs.

Hearing Hardware

This Plan does not cover hearing hardware except as stated on the Summary of Your Costs.

Human Growth Hormone

This Plan does not cover: • 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.

• Drugs or hormones to stimulate growth for idiopathic short stature without growth hormone deficiency

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: • A felony • An act of terrorism • An act of riot or revolt

Infertility

This Plan does not cover: • Services for infertility or fertility problems • 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 • Reversal of voluntary sterilization, including any

direct or indirect complications thereof

Learning Disorders

This Plan does not cover treatment of learning disorders, unless required by law.

Light or Laser Therapy

Low Level Laser Therapy

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: • 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.

Not Covered By The Plan • Services not directly related to an Illness or

Accidental Injury, in excess of the Preventive Services Benefit, including but not limited to routine physical examination and vaccinations for insurance, licensing, traveling or obtaining a passport and recreation programs. All Services related to a Preventive Services Benefit must be provided by an In-network provider.

• Not furnished by a Hospital, Qualified Practitioner or Qualified Treatment Facility, or that are outside the scope of the 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 or supplies were received.

• Provided by homeopaths; massage therapists; faith healers; or unlicensed midwives

• Provided by licensed acupuncturists; naturopathic physicians; chiropractic physicians in excess of the Alternative Care Supplemental Benefit as described under Covered Services and as shown on the Summary of Your Costs, including but not limited to: • Services provided by Out-of-network providers; • Routine or preventive care Services provided by

Acupuncturists or Chiropractors; • Hair analysis; • Electroacupuncture according to Voll (EAV) and

electronic tests for diagnosis and allergy; Tryptophan load test; Zinc tolerancy test; Loomis 24 hours urine nutrient/enzyme analysis; Darkfield examination for toxicity or parasites; comprehensive digestive stool analysis; urine/saliva PH; Cytotoxic food allergy test; salivary caffeine clearance; Sulfate/creatinine ratio; urinary sodium benzoate; fecal transient & retention time; Melatonin biorhythm challenge; intestinal permeability; and Henshaw test;

• Services determined not to be Covered Services under the terms of the Plan;

• Transportation costs including local ambulance charges;

• Biofeedback or vocational rehabilitation; • Massage therapy in the absence of any other

treatment or modality • Vitamins, minerals, nutritional supplements,

remedies, or other similar-type products, whether or not prescribed or recommended by Your Alternative Health Care Provider;



• Legend or non-legend drugs or medicines, except as stated under Covered Services;

• Educational programs, non-medical self-care, or self-help training or any related diagnostic testing;

• Chiropractic Services of strictly non-neuromusculoskeletal disorders.

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.

Non-Medical Detoxification

Detoxification Services that do not consist of active medical management. See Definitions section.

Non-Treatment Facilitated, Institutions or Programs

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.

Not Medically Necessary

This Plan does not cover Services that are not Medically Necessary. This rule also applies to the place where You get the Services.

Obesity Services • Services for surgical and pharmaceutical treatment

of obesity or morbid obesity, and any direct or indirect complications, follow-up services or aftereffects thereof, except to the extent as outlined under the Emergency Care Services provision in the How to Obtain Services section. (An example of an after effect that would not be covered is removal of excess skin and fat that developed as a result of weight loss surgery or the use of obesity drugs.) This exclusion applies to all surgical obesity procedures (inpatient and outpatient) and all obesity drugs and supplements, even if You also have an Illness or Accidental Injury which might be helped by weight loss.

• Dietary therapy including medically supervised formula weight-loss programs or unsupervised self-managed programs utilizing over-the-counter weight loss formulas are not covered unless Services are required by state or federal law.

• All 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.

Orthognathic and Maxillofacial Surgery

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.

Preventive Care

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.

Physical Therapy And Rehabilitation Services

Physical therapy and rehabilitation Services in excess of the physical therapy and rehabilitation benefits; massage therapy in the absence of any other treatment or modality; rolfing; polarity therapy; growth and cognitive therapies; self directed or seminar type of treatment; charges associated with day or overnight facilities for the purpose of intensive nutrition, exercise, educational, relaxation and similar Services; or other Services otherwise excluded by this Plan; and except as shown on the Summary of Your Costs and as described under the Covered Services section.

Prescription Drug Services

Outpatient retail or mail order Prescription Drug Services in excess of the Prescription Drug Benefit as described under Covered Services and as shown on the Summary of Your Costs, including but not limited to: • Vitamins or minerals; • Drugs dispensed for use or administration in a

health care facility or provider’s office; • Take home or discharge medications; • Experimental or Investigational drugs including

drugs labeled “Caution--limited by federal law to investigational use”;

• Professional Services including administration or injection of drugs;

• Allergy Serums; • Prescriptions or refills in excess of the quantity

specified by the prescriber, or that are dispensed after one year from the date the prescription was written; and



• Replacement of lost or stolen medication.

Please visit Our web page at lifewiseor.com for a complete list of Your plan’s covered prescription drug list and to see the benefit coverage available. • Infertility drugs regardless of their intended use;

Private Duty Nursing

This Plan does not cover private duty or 24-hour nursing care. See the Home Health Care benefit for home nursing care benefits.

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.

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.

Services Not Furnished by a Hospital, Licensed Provider or Licensed Treatment Facility

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.

Services of an Institution for the Developmentally Disabled

This Plan does not cover Services of an institution for the developmentally disabled, except while in an acute care Hospital for an Accidental Injury or Illness.

Services Provided for Lodging Accommodations and Transportation

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.

Sexual Problems

This Plan does not cover problems with Your sexual function or response unless required by law. This includes drugs, implants or any complications or effects.

Temporomandibular Joint (TMJ) Disorders

This Plan does not cover Services or supplies connected with the diagnosis or treatment of temporomandibular joint (TMJ) disorders, including any direct or indirect complications, except as shown on the Summary of Your Costs and as described under the TMJ Benefit in the Covered Services section.

Travel Expenses

Communications, lodging accommodations and transportation or travel time except when medical criteria is met and as described under Covered Services.

Vision Services • Services for routine vision examinations and any

type of appliance (and its fittings) used to improve visual sharpness, including glasses and contact lenses.

• Services for any type of appliance (and its fittings) used to improve visual sharpness, including glasses and contact lenses.

• Services for vision therapy, eye exercise, and any type of training to correct muscular imbalance of the eye (orthoptics) and pleoptics.

• Any Services to improve the refractive character of the cornea, including the treatment of any results of such treatment. Covered Services for medical supplies related to cataract removal or corneal surgery are covered under HME, Supplies, Devices, prosthetics and Orthotics as described in the Covered Services.

Voluntary Support Groups

Patient support, consumer or affinity groups such as diabetic support groups or Alcoholics Anonymous.

Weight Loss Surgery or Drugs

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.

Weight Loss Drugs

This Plan does not cover drugs or supplements for weight loss or weight control.

OTHER COVERAGE COORDINATION OF BENEFITS The Coordination of Benefits (COB) with other Plans provision applies when a Member has more than one health Plan.

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.

DEFINITIONS For the purposes of COB: • 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. • "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 subscriber contracts that pay or reimburse for the cost of dental care.

• "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.

• 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.

• 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.

• 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: • 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.

• 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 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.

• 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.

ORDER OF BENEFIT DETERMINATION RULES 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.

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.

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.

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.

• 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 year starting after the Plan is given notice of the court decree.

• If a court decree assigns one parent primary financial responsibility for the child but doesn't mention responsibility for health care expenses, the Plan of the parent with financial responsibility is primary.

• 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.

If there is no court decree allocating responsibility for the child's expenses or coverage, the rules below apply: • The Plan covering the custodial parent, first; • 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.

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.

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.

Length of coverage. The Plan that covered You longer is primary to the Plan that didn't cover You as long.

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.

A Plan may take into account the benefits of another 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.

The secondary Plan must credit to its deductible any amounts it would have credited if it had been primary.

RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION 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.

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.

This Plan has the right to appoint a third party to act on its behalf in recovery efforts.

NON–DUPLICATION OF COVERAGE Coordination with Medicare 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.

NOTICE TO COVERED PERSONS If You are covered by more than one Health Benefit Plan, You should file all Your Claims with each Plan.

THIRD PARTY LIABILITY (SUBROGATION) 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 Plan) 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.

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. Motor vehicle accidents, workplace accidents, injury or Illness, or any other situation 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 (for example, food poisoning or an injury from a defective product) are examples of third party liability. 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.

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.

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 LifeWise employee who specializes in third-party liability/subrogation can discuss with You what Our procedures are and what You need to do.

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.

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 which 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.

We have the right to require You to hold the proceeds of settlement or recovery in trust for the benefit of LifeWise, up to the amount of benefits paid by LifeWise. If We exercise Our right, upon Our notice to You, You must execute an agreement in a form satisfactory to Us to implement the requirement that proceeds of settlement or recovery be held in trust. We will withhold payment of benefits until the agreement is executed and delivered to Us.

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 Plan until all proceeds from the settlement or recovery have been exhausted.

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 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.

Subrogation 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.

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:

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.

Step 2 Attach the bill that lists the Services You received. Your Claim must show all of the following information: • The name of the Member who received the

Services • 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

this 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 Sign the Claim Form

Step 6 Mail Your Claims to:

LifeWise Health Plan of Oregon P O Box 7709 Bend, Oregon 97708-7709

PRESCRIPTION DRUG CLAIMS In-Network Pharmacies 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.

It is very important that You use Your LifeWise ID card at the time You receive Services from an in-network pharmacy. Not using Your LifeWise ID card may increase Your out-of-pocket costs.

Coordination of Prescription Drug Benefits 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.

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 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.

Timely Payment of Claim 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 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.

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.

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.

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; • A description of any additional information needed

to reconsider Your claim and why the information is needed;

• A statement that You have the right to submit a grievance or appeal; and

• A description of the Plan’s Grievance or Appeal processes.

If there were clinical reasons for the denial, You will receive a letter from Us stating these reasons.

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.

If a claim for benefits is denied or ignored, in whole or 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 the Grievance And Appeals section.



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.

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.

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 on the back cover of 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.

We suggest that You call Your provider of care when You have questions about the health care Services they provide.

WHEN YOU HAVE A GRIEVANCE You or Your authorized representative can write to Us when You have a grievance. An authorized representative means and individual who by law or by the consent of a person may act on behalf of the person.

Grievance means: • A complaint in writing about: • The availability, delivery or quality of a health

care Services; • Claims payment, handling or reimbursement for

a health care service that is not disputing an adverse benefit determination; or

• Concerns about Your health Plan or Us.

We will review Your complaint and notify You of the outcome as soon as possible, but no later than 30 days. • A written request for an internal appeal or external

review; • 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 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.

This Plan’s appeal process will comply with any new requirements as necessary under state and federal laws and regulations.

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; • 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;

• A preexisting condition exclusion, source or injury exclusion, network exclusion, or other limitation on otherwise covered benefits;

• A determination that a benefit is Experimental, Investigational, or not Medically Necessary, effective or appropriate.

• 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 How To Obtain Services section of Your Benefit Booklet.

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.

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.

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.

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.

Please call Us for an Authorization for Appeals form. You can also obtain a copy of this form on Our website at lifewiseor.com.

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: • For a Level I internal appeal, within 180 calendar

days of the date You are notified of an adverse benefit determination.

• For a Level II internal appeal, within 60 calendar days of the date You are notified of the Level I determination.

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

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 web page at www.lifewiseor.com.

We will acknowledge Our receipt of Your request in writing within 5 days.

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.

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.

What Happens Next?

We will review Your appeal and provide You with a written decision as stated below: • 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

• 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.

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.

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 and who are qualified to review medical and other relevant information. There is no cost to You for an external review.

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.

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.

We will notify the Oregon Insurance Division (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.

You can also request an external review by contacting the OID. Their contact information is listed below under Other Resources For Help.

The IRO will review Your request and notify You and Us of their decision as stated below: • 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.

• All other external review, within 30 calendar days of the IRO's receipt of Your request.

What Happens Next?

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.

If the IRO upheld Our decision, there is no further review available under this Plan's internal appeals or external review process. However, You may have other remedies available under state or federal law, such a filing a lawsuit.

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.

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.

Oregon Insurance Division, Consumer Protection Unit PO Box 14480 Salem, OR 97309-0405

Call: 503-947-7984 or toll free message line at 888-877-4894

Email: [email protected] On line: http://www.oregon.gov/DCBS/insurance/gethelp/ Pages/fileacomplaint.aspx

Employee Benefits Security Administration (EBSA) 1-866-444-EBSA (3272).

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.



You do not have to be a citizen of or live in the United States if You are otherwise eligible for coverage.

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

• Regularly work the minimum hours required by the Employer/Group Agreement and Employer Provisions; and

• Satisfy any New Employee Waiting Period (Eligibility Waiting Period), if one is required by the Employer/Group Agreement and Employer Provisions.

On-Call, temporary, and substitute and leased employees are not eligible.

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 • A child under 26 years of age.

A child is: • A natural offspring of either or both the employee

or Spouse • A legally adopted child of either or both the

employee or Spouse • A child “placed” with the Employee for the

purpose of legal adoption in accordance with state law

• A legally placed ward of the Employee or Spouse (including foster children) living permanently in the home of the Employee; or

• A grandchild of either or both the Employee or Spouse 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 placement with an employee ends upon the termination of such legal obligations. A Dependent covered as a child under the Plan will remain eligible after age 26 if they are: • Developmentally disabled or permanently

physically handicapped; • Incapable of self-sustaining employment; and

• Unmarried and primarily Dependent upon the employee for support.

Within 60 days of the Dependent reaching their 26th birthday, and upon 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.

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.

The 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.

Newborn Child and Adopted Child Eligibility And Enrollment

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.

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.

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 can be accomplished as outlined in this section under Enrollment Provisions For Late And Special Enrollees.

Special Conditions Regarding Dependent Coverage • 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 child becomes an Employee of the Employer/Group, he or she is no longer a Dependent and must make application as an Employee

EFFECTIVE DATE OF COVERAGE Employee Effective Date

The Effective Date of Coverage provision is stated in the Employer/Group Agreement or another date as requested in writing by the Employer/Group and approved by LifeWise. If You are a late enrollee, as specified within this section, Your Effective Date of coverage is described under Special Provisions for Late Enrollees.

Dependent Effective Date

Each Dependent is eligible for coverage on: • The first of the month following 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’s marriage for any Dependents acquired on that date;

• The date of birth of the natural-born child of the Employee or Spouse;

• The date the child is placed with the Employee or Spouse for the purpose of adoption;

• The first of the month following the date a qualified medical support court or administrative order to provide health coverage for a child (including foster children) of an Employee or Spouse.

ENROLLMENT PROVISIONS FOR LATE AND SPECIAL ENROLLEES There are special provisions for enrollment in this Plan if You 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.

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. 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.

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 qualifies as a Special Enrollee if:

• 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; or

• You apply for coverage during a Special Enrollment Period; or

• There is a court order that is not more than 30 days old that orders a Spouse or minor child be covered under this Plan; or

• You are employed by an employer who offers multiple Health Benefit Plans and You elect to enroll with LifeWise in lieu of a different health Plan: • On which You have been covered until that time, • During an annual group enrollment period; or • You have a change in Your family status due to

marriage, birth, adoption or placement for adoption

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 the 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.

Special Enrollees Who Have Lost Their Other Coverage

If You have declined enrollment for yourself or Your Dependents (including Your Spouse) because of other group health coverage, You may enroll yourself and/or 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: • 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

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; or

• 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

• Reduction in the number of hours of employment, children aging out of coverage, or

• Moving out of an HMO Service Area and there is no other coverage available with the other Plan.

• The current or former employer contributions towards such coverage were terminated; and

• The person requests enrollment under this Plan not later than 30 days after the date such other coverage ended.

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.

Special Enrollees Who Have A Change In Family Status

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 special enrollment period is 30 days and begins on the later of: • The date Dependent coverage is made available

under the Plan; or • 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;

• In the case of a Dependent’s birth, on the date of such birth; or

• 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.

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 Eligibility and Enrollment and: • You qualify for Premium assistance for this Plan

from the Oregon Health Plan or CHIP; or • You no longer qualify for health care coverage

under the Oregon Health Plan or CHIP.

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.

Coverage under this Plan for the Employee or Dependent will start on the first of the month following: • The date the Employee or Dependents qualify for

the Oregon Health Plan or CHIP Premium assistance; or

• 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.

CHANGES IN COVERAGE No rights are vested under this Plan. Its terms, benefits, and limitations may be changed at any time. With one exception, all changes to this Plan will apply, as of the date the change becomes effective to all Members that become covered under this Plan after the date the change becomes effective.

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 Plan, that person shall be eligible for coverage under this Plan without regard to active



status or Hospital confinement.

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 Plan 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.

• In applying any deductibles or benefit exclusion 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.

• 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.

ELIGIBILITY STATUS CHANGES DUE TO LEAVE OF ABSENCE, LAYOFFS AND REDUCTION IN WORK HOURS An enrolled Employee on an Employer/Group approved leave of absence, for any reason, may continue to be covered under this Plan as though in active status for a period not to exceed three (3) months. Absences extending beyond this time period will be subject to the provisions outlined under Continuation of Coverage.

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. 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. 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 Plan.

TERMINATION OF COVERAGE WHEN COVERAGE ENDS Termination of coverage will occur on the earliest of the following: • The date this Plan terminates; • The end of the period for which required Premium

was due to Us and not received by Us; • For the Employee, the end of the month in which

he no longer qualifies as an Employee or terminates employment with the Employer/Group;

• For the Employee, the end of the month in which he fails to pay required Premiums;

• For the Employee, the end of the month in which he 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 the Employee requests termination of coverage to be effective for the Employee or Member;

• For a Dependent, the date the Employee’s coverage terminates;

• For a Dependent, the end of the month he or she no longer qualifies as a Dependent;

• For any benefit, the date the benefit is deleted from this Plan;

• For You or the Employer/Group, the date We discover any breach of contractual duties, conditions or warranties, as determined by Us;

• For You or the Employer/Group, the end of the month that the Employer/Group terminates its participation in a multiple employer trust or association.

We may rescind Your coverage upon the discovery of fraud, or material misrepresentation of material fact, regarding any terms, conditions or benefits of the Plan.

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.

Non-Liability after Termination

Upon termination of this Plan, 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 Plan has terminated.

If the Employer/Group has immediately replaced this Plan with an 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 Plan have been reached, whichever is earlier.

CONTINUATION OF COVERAGE 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 coverage.

FOR GROUPS WITH 20 OR MORE EMPLOYEES 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.

Special Notice

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 of marriage or registered domestic partnership 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: • The failure to pay Premiums when due, including

any grace period; • The date that the contract is terminated; • The date on which the Spouse becomes insured

under any other group health plan; • The date on which the Spouse remarries and

becomes covered under another group health plan; or

• The date on which the Spouse becomes eligible for

federal Medicare coverage.

FOR GROUPS NOT SUBJECT TO COBRA OR WITH FEWER THAN 20 EMPLOYEES 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.

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: • Coverage ends because of the termination of

employment of the Employee, or • Coverage ends because the Employee’s reduction

in work hours, or • Coverage ends because of the death, dissolution of

marriage or registered domestic partnership, or legal separation;

• Coverage ends because the employee becomes eligible for Medicare; or

• Coverage ends because the enrolled Dependent no longer qualifies as a Dependent.

You must request state continuation coverage in writing and pay 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: • 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

• 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)

• Medicare: First of the month in which You become entitled to Medicare benefits

• Other Group Coverage: The date You become covered under another group health Plan as a covered employee or as a dependent; or



• Remarriage: The date the former Spouse remarries and, because of the remarriage, becomes covered under another group health Plan.

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 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.

Coverage under this paragraph shall continue until the first of the following occurs: • Less than seventy five percent (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.

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: • The Employee takes full-time employment with

another employer; or • Nine (9) months from the date that the payment of

Premium is made under this provision.

Coverage Extensions

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.

OTHER PLAN INFORMATION In this section, We have listed other Plan provisions and State and Federal Notices.

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 Plan. 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.

Compliance With Law

The Association/Group shall comply fully with all applicable state, federal and local laws and regulations, including notice and disclosure requirements, in carrying out its responsibilities under the Contract. These include, but are not limited to, compliance with the Internal Revenue Code, the Employee Retirement Income Security Act of 1974 (ERISA), the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the Family and Medical Leave Act of 1993 (FMLA), and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In addition, if the Plan provides coverage for retirees, the Employer/Group is also subject to the notice requirements of the Balanced Budget Act of 1997.

Conformity with the Law

The contract is issued and delivered in the State of Oregon and is governed by the laws of the State of Oregon, except to the extent preempted by federal law. In the event any provision of the Plan or any amendment is deemed to be in conflict with applicable state or federal laws or regulations, upon discovery of such conflict the Plan will be administered in conformance with the requirements of such laws and regulations as of their effective date.



Duplicating Provisions

If any charge is described as covered under two or more benefit provisions, We will pay only under the provision allowing the greater benefit. This may require Us to make a recalculation based upon both the amounts already paid and the amounts due to be paid. We have no liability for benefits other than those this Plan provides.

Employer/Group As The Agent

The employer/group is the agent of the Members for all purposes under this Plan 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 the following: • This Benefit Booklet • The Employer/Group Provision • The Employer Group Agreement and Benefit

Selections form • All Endorsement included now or issued later.

Failure To Provide Information Or Providing Incorrect Or Incomplete Information

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 Plan 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 Plan.

In addition, if the Employer/Group fails to furnish information as required to be furnished under terms of this Plan, 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.

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.

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.

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.

The following disclosures are available: • LifeWise drug formularies • LifeWise process for credentialing in-network

providers and their qualifications • LifeWise Annual Summary of Network Adequacy • LifeWise Annual Summary of Grievance and

Appeals • LifeWise Annual Summary of Utilization Review

Policies • The results of all publically available accreditation

surveys

You may also request a copy of Our Annual Summaries from the Department of Consumer and Business Services. You can contact them as follows:

By calling: (503) 947-7984 or their toll-free message line at: (888) 877-4894

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].

Interpretation of Plan

To the extent this Plan is governed by the Employee Retirement Income Security Act of 1974 (ERISA), as amended, the Employer/Group’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.

• 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 gives LifeWise, as acting for the “Plan Administrator”, the discretionary authority to determine eligibility for benefits under the Plan and to interpret the terms of the Plan.

Legal Action

No legal or equitable action may be brought to recover benefits from this contract until receipt of a final decision from the LifeWise Grievance Committee. No such action will be brought three years after receipt of the decision of the LifeWise Grievance Committee.

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.

LifeWise Not Liable For Quality Of Medical Care

LifeWise is not responsible for the quality of medical care a person receives since all those who provide care do so as independent contractors. We are not liable for any claim or demand on account of damages arising out of or in any manner connected with any injuries suffered by You while receiving Services.

LifeWise Privacy Policy and Notification Practices

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 other groups.

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 • Care management, health support programs,

utilization or quality reviews • Meeting other legal obligations that are specified

under this policy

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.

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.

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.

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.

It is Your responsibility to read and to understand the terms of this policy. We will have no liability for Your 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.

Misstatement of Age

If the age of the insured has been misstated, all amounts payable under the Plan is such as the Premium paid would have purchased at the correct age.

Modification Of The Contract and Notification of Plan Change

We may change or amend the Contract as provided in the Employer/Group Provisions section. We will: • Contact the Employer/Group in writing regarding

the change; • Provide a description of the change and how it



affects the Contract; and • Provide a copy of any pertinent information such as

a revised Contract form or Endorsement.

Credit will be applied to Benefit Maximum Limits, Durational Limits, Deductibles and Out-of-Pocket Limit provisions if the benefits for Covered Services under this Contract are modified, or if Your Employer/Group changes to another LifeWise Contract. However credit is given only to the extent that these provisions are applicable under the terms of the Contract prior to the modification or change.

Any notice required of Us under this Plan shall be deemed to be sufficient if mailed to the enrolled Employee at the address appearing on the records of LifeWise. Any notice required of the Employer/Group or You, shall be deemed sufficient if mailed to the principal office of LifeWise Health Plan of Oregon, P.O. Box 7709, Bend, Oregon 97708-7709.

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).

Provider Credentialing And Recredentialing

LifeWise in-network providers must be credentialed by LifeWise in accordance with LifeWise administrative credentialing policies. You may obtain a copy of Our credentialing policies by calling Us at the number listed in the front of this Benefit Booklet or by writing to LifeWise Health Plan of Oregon at P.O. Box 7709, Bend, Oregon 97708-7709.

Non-Transferability of Benefits

No person other than a Member is entitled to receive benefits under this Plan. Such right to benefits is nontransferable.

Nonwaiver

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.

Representation Not Warranties

In the absence of fraud, all statements made by the applicant, Employer/Group or Member shall be considered representations and not warranties. No statement made while applying for insurance will cancel insurance or reduce benefits unless it is in a written document signed by the Employer/Group or insured person. A copy of the document must be given to the person noted.

Recovery of Claims Overpayments

We have the right to recover money We overpay in error. We may recover this money from the employee 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.

Severability

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.

Workers’ Compensation Insurance

This Plan is not in lieu of, and does not affect, any requirement for coverage by Workers’ Compensation insurance.

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.

DEFINITIONS 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.

Accidental Dental Injury

Accidental Dental Injury means a dental injury caused



by a sudden and unforeseen event at a specific time and place. It does not include injuries caused by biting or chewing.

Accidental Injury

Physical harm caused by a sudden, unexpected event at a certain time and place.

Accidental Injury does not mean any of the following: • An Illness, except for infection of a cut or wound • Over-exertion or muscle strains

Affordable Care Act

The Patient Protection and Affordable Care Act of 2010 (Public Law 111-148) as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).

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 • It is a permanent facility that is equipped and run

mainly for doing surgical procedures • It does not provide Inpatient Services or rooms

Annual Group Enrollment

Annual Group Enrollment means a period of at least 30 days each Year, agreed to by Us and the Employer, during which Employees are given the opportunity to enroll themselves and/or their Dependents in the Plan for the upcoming Contract Year, subject to the terms and provisions found under Eligibility and Enrollment.

There will be an Annual Group Enrollment Period each Contract Year. The Effective Date of Coverage for new Members who enroll during the Annual Group Enrollment Period is the beginning of the Contract Year for which they enroll.

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.

Benefit Exclusion Period

Benefit Exclusion Period means a period during which specified treatment or Services are excluded from coverage.

Benefit Maximum Limit

Benefit Maximum Limit means the maximum amount of benefits paid by the Plan for certain Covered

Services. Benefit Maximum Limit amounts are listed on the Summary of Your Costs.

Calendar Year (Year)

A 12-month period that starts each January 1 at 12:01 a.m. and ends on December 31 at midnight.

Chemical Dependency

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: • Losing control over the amount and circumstances

of use • 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.

Chemical Dependency Center

Chemical Dependency Center means any facility for the treatment of Chemical Dependency, which is duly licensed by the appropriate state agency, and is primarily established and operating within the scope of its license.

Claim

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 allowed amount. Coinsurance amounts are listed in the Summary of Your Costs.

Complications of Pregnancy

A medical condition related to pregnancy or childbirth that falls into one of these three categories: • A condition of the fetus that needs surgery while

still in the womb (in utero surgical intervention) • A disease the mother has that is not caused by the

pregnancy but is made worse by the pregnancy • 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: • Ectopic pregnancy



• Hydatidiform mole/molar pregnancy • Incompetent cervix that requires treatment • Complications of administration of anesthesia or

sedation during labor or delivery • Obstetrical trauma uterine rupture before onset

or during labor • Hemorrhage before or after delivery that requires

medical/surgical treatment • Placental conditions that require surgical

intervention • Preterm labor and monitoring • 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).

Congenital Anomaly

A body part that is clearly different from the normal structure at the time of birth.

Contract Year

Contract Year means a one-year time period starting from the effective date of the Contract.

Copay (Copayment)

A Copay is a set dollar amount You must pay Your provider. You pay a Copay at the time You get care.

Cosmetic Service

Cosmetic Service means Services performed to reshape normal structures of the body in order to improve Your appearance and self-esteem and not primarily to restore an impaired function of the body.

Cost-Share

The Member’s share of the allowable charge for Covered Services. Deductibles, Copayments, and Coinsurance are all types of Cost-Shares. See the Summary of Your Costs to find out what the Cost-Share is for the Covered Service provided.

Covered Service

A service, supply or drug that is eligible for benefits under the terms of this Plan.

Creditable Coverage

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

one of the following: • Group coverage, including the Federal Employees

Health Benefits Plan, State Children’s Health Insurance Program and the Peace Corps

• Individual coverage • Student health Plan • Medicare, Medicaid, TRICARE • Indian Health Services or tribal organization

coverage • State high-risk pool • 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

Custodial Care

Any part of a service, procedure, or supply that is mainly to: • Maintain Your health over time, and not to treat

specific Illness or injury • 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.

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.

Dentally Necessary

Those Covered Services which are determined to meet all of the following requirements: • 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

• Appropriate and consistent with authoritative dental or scientific literature

• Not primarily for the convenience of the Member, the Member’s family, the Member’s dental care provider or another provider

Dependent

The employee’s Spouse or Domestic Partner and any children who are enrolled on this Plan.



Detoxification

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.

Durational Limit

Durational Limit means the total amount of days or visits allowed for certain benefits and/or the specific time period in which benefits are allowed. Durational Limits are listed in the Summary of Your Costs.

Effective Date of Coverage

The date when Your coverage begins under this Plan. If You re-enroll in this Plan after a lapse in coverage, the date that the coverage begins again will be Your Effective Date of Coverage.

Eligibility Waiting Period

The length of time that must pass before an Employee or dependent is eligible to be covered under a group’s health care plan. If an Employee or dependent enrolls under the “Special Enrollment” provisions of this program or enrolls on a date other than when first eligible to enroll, any period prior to such enrollment is not considered an Eligibility Waiting Period, unless all or part of the initial Eligibility Waiting Period had not been met.

Emergency Medical Condition

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: • Place the health of a person, or a fetus in the case

of a pregnant woman, in serious jeopardy. • Result in serious impairment to bodily functions; or • 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.

Emergency Medical Screening Exam

The medical history, examination, ancillary tests and medical determinations required to ascertain the nature and extent of an Emergency Medical Condition.

Emergency Services

Emergency Services:

• 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.

Employer/Group

The sponsor of this Plan, or any related entity described in the Employer/Group Agreement. To be covered by this Plan, an individual employer must meet the definition of Employee.

Employee

An Employee that is eligible to enroll in the Plan

Endorsement

A document that is attached to and made a part of this contract. An Endorsement changes the terms of the contract.

Enrollment Date

The first day of coverage or, if there is an Eligibility Waiting Period, the first day of the Eligibility Waiting Period.

Experimental/Investigational Procedures

Services that meet one or more of the following: • 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

• It is subject to oversight by an Institutional Review Board

• There is no reliable evidence showing that the service is effective in clinical diagnosis, evaluation, management or treatment of the condition

• It is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety or efficacy

• Evaluation of reliable evidence indicates that additional research is necessary before the service can be classified as equally or more effective than conventional therapies

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, medical expense or Hospital and medical contract or certificate, health care service contractor or health maintenance organization 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.

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.

Hospital

A healthcare facility that meets all of these criteria: • It operates legally as a Hospital in the state where it

is located • It has facilities for the diagnosis, treatment and

acute care of injured and ill persons as Inpatients • 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

A facility is not considered a Hospital if it operates mainly for any of the purposes below: • As a rest, nursing, or convalescent home • As a residential treatment center; or health resort • To provide hospice care for terminally ill patients • To care for the elderly • To treat Chemical Dependency or tuberculosis.

Illness

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 Inpatient.

LifeWise Health Plan Of Oregon

LifeWise Health Plan of Oregon (LifeWise) is the organization providing benefits for health care Services.

Master Group Contract

The Master Group Contract (Contract) consists of the Employer/Group Agreement, Employer Provisions, Benefit Booklet(s), any applicable Endorsements and

Underwriting Agreements and is also referred to as the Plan.

Provisions and Benefit Booklet(s), any applicable Endorsements and is also referred to as the Plan.

Medically Necessary

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: • Agree with generally accepted standards of

medical practice • Be clinically appropriate in type, frequency, extent,

site and duration and must also be considered effective for the patient’s Illness, injury or disease

• Not primarily for the convenience of the patient, Physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s Illness, injury or disease.

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.

Member

Any person covered under this Plan.

Mental or Nervous Conditions

All mental health disorders identified in the Diagnostic and Statistical Manual (DSM). DSM IV-TR or the Diagnostic and Statistical Manual (DSM), fifth Edition, DSM 5.

Nicotine Dependency

The use of nicotine 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.

Off Label Prescription Drugs

Off label use of Prescription Drugs is when a drug is prescribed for a different condition than the one it was approved for.

Orthotic

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.

Outpatient

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.

Pervasive Developmental Disorder

Pervasive Developmental Disorder means a neurological condition that includes developmental delay, developmental disability or mental retardation.

Plan

The benefits, terms, and limitations set forth 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.”

Physician

A state licensed Doctor of Medicine and Surgery (M.D.) or Doctor of Osteopathy (D.O.).

This Plan covers professional Services from the following providers as if they were provided by a Physician as defined above: • Certified Nurse Practitioner • Chiropractor (D.C.) • Dentist (D.D.S. or D.M.D.) • Denturist • Naturopathic Physician (N.D.) • Obstetrical and Gynecology (OB/GYN) • Oral Surgeon • Optometrist (O.D.) • Physical Therapist (P.T.) • Podiatrist (D.P.M.) • Psychologist (Ph.D.)

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.

Prior Authorization

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.

Qualified Clinical Trials

A Qualifying Clinical Trial is a clinical trial that is funded and supported by the National Institutes of Health, the Centers 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.

The Qualified Clinical Trial must be conducted as an investigational new drug application, and investigational device exemption or a biologics license application subject to approval by the United States Food and Drug Administration (FDA). Also, a Qualified Clinical Trial is exempt by federal law from the requirements to submit an investigational new drug application to the FDA.

We encourage You or Your provider to call Customer Service to answer any coverage questions you may have regarding benefits. You or Your provider can call Us at the number listed on Your LifeWise ID Card.

Qualified Treatment Facility

Qualified Treatment Facility means only a facility, institution, or clinic duly licensed by the appropriate state agency, and is primarily established and operating within the scope of its license.

Reconstructive Surgery

Reconstructive Surgery is surgery: • Which restores features damaged as a result of

Accidental Injury or Illness; or • To correct a congenital deformity or anomaly.

Service Area

Service Area is the state of Oregon.

Services

Services are procedures, surgeries, consultations, advice, diagnosis, referrals, treatment, supplies, drugs, devices or technologies.

Skilled Care

Medical care that is ordered by a Physician and requires the medical knowledge and training of a



licensed registered nurse.

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.

Sound 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; and • Is not more susceptible to injury than a whole

natural tooth.

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.

Spouse

Spouse means an individual who is married to or a registered Domestic Partner (as defined by Oregon statute) of the employee.

Supplemental Benefit

Any Supplemental Benefit attached hereto and made a part of the Contract that operates to change and supersede any of the terms or conditions set forth in the printed Contract.

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

We, Us and Our means LifeWise Health Plan of Oregon

You and Your

You and Your means any Member enrolled in this Plan.

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

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