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The following chart shows key features of your medical options. If you need more information about your medical options, refer to your benefits booklet. You may also contact the health plan's customer service for further assistance.
Services |
PPO
Network Provider - Insured Pays |
Non-Network
Provider - Insured Pays |
| Your Policy Maximum While Insured | $2,000,000 |
|
| Calendar Year Deductible | ||
| Individual | $250 |
|
| Family Maximum (2x Individual) | $500 |
|
| Medical Calendar Year Out-of-Pocket Maximum | ||
| Individual | $2,000 + Deductible |
$6,000 + Deductible |
| Family Maximum (2x Individual) | $4,000 + Deductible |
$12,000 + Deductible |
| Physician Services | ||
| Office Visits | $15 office
visit copay* (2) |
40% after Deductible
(2) |
| Routine Physical Exams | $15 office
visit copay* (3) |
40% after Deductible (3) |
| Well Baby/Child Care | $15 office
visit copay* (3) |
40% after Deductible (3) |
| Maternity | $250
copay per pregnancy* (4) |
40% after Deductible |
| Other Professional Services | ||
| Routine Lab and X-Ray | 20%,
Deductible waived |
40%
after Deductible |
| CT Scans, MRI, PET Scans | 20%, Deductible
waived |
40% after
Deductible |
| DME/Supplies | 20% after Deductible |
40% after Deductible |
| Alternative Care | 20% after Deductible*
(8) |
Not Covered |
| Hospital Services | ||
Inpatient Services |
20% after Deductible |
40% after Deductible |
| Surgeon/Anesthesiologist Services | 20% after Deductible |
40% after Deductible |
Inpatient Rehab Care |
20% after Deductible
(9) |
40% after Deductible (9) |
| Outpatient Surgery Facility Fee and Procedure | 20% after Deductible |
40% after Deductible |
| Emergency Room Services | $75
copay, then 20% after Deductible - waived if admitted |
|
| Mental Health / Chemical Dependency | As
required by Oregon State Mandates |
|
(1) Each enrolled member must select a Primary Care Practitioner;
Specialist must be contracted with PCP.
(2) Allergy Shots & Therapeutic injections (serum not included) and other
office procedures are covered at 20% after the deductible for In-Network providers
and at 40% after the deductible for Non-Network providers.
(3) $500 per calendar year (PCY) maximum for preventive service. Routine
Immunizations/Vaccinations are covered in full and not included in PCY limit
for In-Network providers and 40% for Non-Network providers.
(4) Maternity In-Network copay covers Prenatal, Delivery & Postnatal
Physician Services. Mother and newborn are subject to separate deductible and
coinsurance for hospital services.
(5)When referred to a specialist, $30 office visit copay applies.
(6)Maternity care from a specialist is subject to a $150 copay per pregnancy.
(7)$0 copay for prenatal care; $15 copay for children over age 2.
(8) Alternative Care includes: Chiropractic, Naturopathic, and Acupuncture. Providers
are the LifeWise network and limited to $1,500 PCY.
(9)
Inpatient Rehab Care: 60
day maximum PCY.