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Benefit plans typically have exclusions and limitations - what the
plans do not cover. The following are general exclusions and
limitations for the LifeWise benefit plans. |
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What Is Not Covered (Exclusions) |
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Benefits are not provided for
treatment, surgery, services, drugs or supplies for any of the
following: |
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Chemical
dependency or tobacco addiction
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Cosmetic
or reconstructive surgery (except as specifically provided)
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Dental
services (except as specifically provided)
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Experimental or investigative services
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Hearing
examinations or hardware
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Infertility
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Learning
disorders
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Neurodevelopmental disabilities
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Obesity/morbid obesity
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Orthognathic surgery (surgery to correct abnormal position of the
jaws), except when repairing a dependent child's congenital
abnormality
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Orthotics (making and fitting of orthopaedic appliances), except for
treatment of diabetes
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Over-the-counter or non-prescription drugs
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Services
in excess of specified benefit maximums
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Services
payable by other types of insurance coverage
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Services
received when you are not covered by this program
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Sexual
dysfunction
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Sterilization reversal
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Temporomandibular joint (TMJ) disorder
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Other Exclusions and Limitations to Coverage |
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Pre-existing conditions: no
benefits for treatment related to pre-existing conditions (including
maternity) during the
first 9 months of coverage, unless otherwise specified.
A pre-existing condition is
a condition for which medical advice was given, for which a health
care provider recommended or provided treatment, or for which a
prudent layperson would have sought advice or treatment, within the
six months prior to the effective date
of the plan.
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No
benefits for treatment related to transplants during the first 12
months of coverage.
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Maternity/obstetrical care is not covered under WiseEssentials and
WiseSavings plans.
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Prescription drugs are not covered under WiseEssentials and
WiseSavings plans.
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Routine Vision
Care is not covered under WiseEssentials and WiseSavings plans.
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Allergy
testing and injections are not covered under the WiseEssentials
plan.
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Disposable diabetic supplies are not covered under the
WiseEssentials and WiseSavings plans.
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Important
Information About This Benefit
Summary |
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This is a brief summary of benefits; it is
not a contract or a certificate of coverage, nor is it a complete
explanation of plan benefits or exclusions and limitations for LifeWise
Health Plan of Washington plans. The complete terms of coverage
are determined by the carrier's contract. While we have accurately
represented the information in this Benefit Summary as of the time it was
published, should any discrepancies exist between this Benefit Summary and
the carrier's contract, the carrier's contract shall prevail. Please refer
to the carrier's contract for a complete statement of benefits including
waiting periods, limitations and exclusions.
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