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Index | Exclusions
& Limitations | Locate
Providers | Locate
Pharmacy | Application
Plan Benefits:
Maximizer | Beneficial Value (PPO)
| Beneficial Rx (PPO) | HSA Value | HSA
Choice
Plan Rates:
Maximizer | Beneficial Value (PPO) | Beneficial
Rx (PPO) | HSA Value | HSA
Choice
Oregon Medical Insurance > ODS Health Plans of Oregon > Beneficial Value Benefits
|
Beneficial Value (PPO)
|
||
| Lifetime benefit maximum |
$2,000,000
($250,000 can be accessed out of network) |
|
| Plan year deductible, individual (family is 3x the individual) |
$1,000 / $2,500 / $5,000 / $7,500
|
|
| Out-of-pocket maximum, per
person (after deductible) |
$5,000
|
$10,000
|
| Preventive Care |
Member Responsibility
|
|
|
In-Network
|
Out-of-Network
|
|
| Annual women's exam, pap test, pelvic and breast exam |
$25 co-pay*
|
50%
|
| Women's routine mammogram |
$25 co-pay*
|
50%
|
| Well-baby care, primary care physician (PCP) |
$25 co-pay*
|
Not covered |
| Routine physical exams |
$25 co-pay*
|
Not covered
|
| Immunizations |
$0*
|
Not covered
|
| Professional Services | ||
| Office visits |
First 3 at $25**
|
50%
|
| Alternative care ($1,000 per plan year
limit) Chiropractic, naturopathic and acupuncture |
First 3 at $25**
|
50% |
| Maternity | ||
| All pre/post office visits and doctor
delivery; hospital charges (12 month exclusion period) |
30%
|
50%
|
| Hospital Services | ||
| Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care |
30%
|
50%
|
| Emergency Services (deductible applies) |
||
| Urgent Care |
$25** co-pay
|
50%
|
| Hospital emergency room |
30% after $100 copayment
|
|
| Ambulance |
30%
|
|
| Other Facilities and Services | ||
| Lab and X-ray services, rehabilitation services, medical supplies and devices; in-hospital care; home healthcare |
30%
|
50%
|
| Prescription services |
***Optional $15 generic or 50% , $2,000 max; deductible waived.
|
|
| Accident benefit | Deductible waived for treatment completed within 90 days | |
|
*The plan deductible is waived for these
services. ***Can purchase prescription rider separately; benefit is $15 generic or 50% brand, $2,000 maximum benefit; deductible waived. Fixed dollar copayments, out-of-pocket expenses for prescription drugs and disallowed charges do not apply to the annual deductible or to the out-of-pocket maximum. Expenses applied toward the annual deductible do not aply to the out-of-pocket maximum. Expenses for transplants performed at non-participating transplant facilities and service authorization cost containment penalty do not apply to the out-of-pocket maximum. |
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