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Oregon Medical Insurance > HealthNet of Oregon > Emerald 40 Benefits


 
Emerald 40 Plan
In-Network
Out of Network
Deductible Choices
The deductible Coverage Year (CY) is January 1 through December 31
Individual: $1,000, $2,500, $5,000, $7,500 or $10,000 (4,5)
Family = 3x Individual
Lifetime maximum
$2,000,000 combined
Out-of-pocket maximum (OPM)

Individual

$6,000 (7)
$12,000 (7)

Family

$18,000 (7)
$36,000 (7)
Professional Services
Office visit
$40 (6)
50% UCR+
Well Baby Care (8 exams in the first 24 months) (6)
$40 (6)
50% UCR+
Annual OB/GYN exam
(breast and pelvic exams, cervical cancer screening & mammography) (6)
$40 (6)
50% UCR+
X-ray and laboratory procedures
30%
50% UCR+
Outpatient Services
Outpatient or ambulatory care center
30%
50% UCR+
Outpatient rehabilitation therapy
($2,500/year max)
30%
50% UCR+
Outpatient facility services
(other than surgery)
30%
50% UCR+
Maternity care
Physicians services for maternity care
30%
50% UCR+
Hospitalization services
Inpatient hospital care
30%
50% UCR+
Skilled nursing facility care
(60 days per year max)
30%
50% UCR+
Inpatient rehabilitation therapy
(30 days per year max)
30%
50% UCR+
Emergency health coverage
Outpatient emergency room services
30%
50% UCR+
Inpatient admission from emergency room
30%
50% UCR+
Emergency ambulance
(up to $3,000 per year)
30%
30% UCR+
Additional Accident
Accidental injury deductible waiver **
30%
(Deductible waived)
50%
(Deductible waived)
Prescription Benefit***
$100 Rx deductible; up to $2,000 per year
In Pharmacy
(Per Fill Up to a 30-day Supply)
Mail Order
(Per Fill Up to a 90-day Supply)

Tier 1 drug list
50%
50%

Tier 2 drug list
50%
50%

Tier 3 & Specialty
You pay 100%***
Preventive benefits
Routine physical, prostate screening, vision screening (6)
Included
Well Net Complementary Care
$500 annual benefit (6)
Not included

Chiro, acupuncture, naturopathy
Not included

Massage Therapy
Not included

Notes:

**Diamond 15, Topaz First Dollar, and Emerald 40 plans include an Additional Accident benefit. The Calendar Year deductible may be waived for treatment of accidental injury in an Emergency Room (ER) or Urgent Care (UR) facility. ER or UR copays or coinsurance will still apply and follow up treatment is subject to Plan benefits. The Waiver Request form is available through Customer Service, and must be filed within 90 days of the injury.

(4) Unless otherwise specified, you must meet the Calendar Year deductible before Health Net pays any claims.
(5) Your deductible payments do not apply to the annual out-of-pocket maximum.
(6) The CY deductible is waived
(7) The annual out-of-pocket maximum does not include the annual deductible. After you reach the out-of-pocket maximum in a calendar year, we will pay your covered services during the rest of that calendar year at 100% of our contract rates for PPO services and at 100% of UCR for out-of-network (OON) services. You are still responsible for OON billed charges that exceed UCR.

PRESCRIPTION DRUG PROGRAM

*** In Pharmacy: Prescription drugs may be filled at a participating pharmacy (up to a 30-day supply). Mail Order: Prescription drugs may be filled through our participating mail pharmacy (up to a 90-day supply). When Tier 3 brand name drugs are not covered, members will still have the advantage of Health Net's pharmacy discounts..

Refer to your contract for details, limitations and exclusions.

 
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