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FAX - 541.284.2994
Plan Benefits:
Diamond 15 | Pearl 25 HMO | Emerald 40 | Garnet 50 | Topaz | Crystal 80 HDHP | Crystal 100 HDHP
Plan Rates:
Diamond 15 | Pearl 25 HMO | Emerald 40 | Garnet 50 | Topaz | Crystal 80 HDHP | Crystal 100 HDHP
Oregon Medical Insurance > HealthNet of Oregon > Crystal HDHP 80% Benefits
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Crystal HDHP 80% Plans
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In-Network
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Out of Network
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| Deductible Choices The deductible Coverage Year (CY) is January 1 through December 31 |
Individual: $1,500,
$2,500, or $3,500 (1) |
Individual: $3,000,
$5,000, or $,7000 (1) |
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Family: $3,000,
$5,000, or $7,000 (1) |
Family: $6,000,
$10,000 or $14,000 (1) |
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| Lifetime maximum |
$2,000,000 combined
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| Out-of-pocket maximum (OPM) | ||
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$5,000 (2)
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$15,000 (2)
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$10,000 (2)
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$30,000 (2)
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| Professional Services | ||
| Office visit |
20%
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50% UCR+
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| Well Baby Care (8 exams in the first 24 months) (6) |
20%
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50% UCR+
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| Annual OB/GYN exam (breast and pelvic exams, cervical cancer screening & mammography) (6) |
20%
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50% UCR+
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| X-ray and laboratory procedures |
20%
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50% UCR+
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| Outpatient Services | ||
| Outpatient or ambulatory care center |
20%
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50% UCR+
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| Outpatient rehabilitation therapy ($2,500/year max) |
20%
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50% UCR+
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| Outpatient facility services (other than surgery) |
20%
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50% UCR+
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| Maternity care | ||
| Physicians services for maternity care |
20%
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50% UCR+
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| Hospitalization services | ||
| Inpatient hospital care |
20%
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50% UCR+
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| Skilled nursing facility care (60 days per year max) |
20%
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50% UCR+
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| Inpatient rehabilitation therapy (30 days per year max) |
20%
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50% UCR+
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| Emergency health coverage | ||
| Outpatient emergency room services |
20%
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50% UCR+
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| Inpatient admission from emergency room |
20%
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50% UCR+
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| Emergency ambulance (up to $3,000 per year) |
20%
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20% UCR+
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| Additional Accident | ||
| Accidental injury deductible waiver ** |
Not included
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| Prescription Benefit*** Subject to medical deductible |
In Pharmacy
(Per Fill Up to a 30-day Supply) |
Mail Order
(Per Fill Up to a 90-day Supply) |
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50%
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50%
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50%
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50%
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You pay 100%***
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| Preventive benefits | ||
| Routine physical, prostate screening, vision screening |
Included
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Notes: (1) The deductible must be met each calendar year (January 1 through
December 31) before Health Net pays any claims. With this plan, the deductible
applies to the annual out-of-pocket maximum. Family coverage means the
subscriber and spouse; the subscriber and child(ren); or the subscriber,
spouse and child(ren). Under family coverage, each member’s covered
expenses count toward the deductible, but the specified family coverage
deductible must be met before Health Net pays any claims. PRESCRIPTION DRUG PROGRAM
Refer to your contract for details, limitations and exclusions. |
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