ODS Maximizer PPO Benefits

Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994

	Maximizer
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
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, pelvic, breast	$20 co-pay*	50%
Women's routine mammogram	$20 co-pay*	50%
Well-baby care	$20 co-pay*	Not covered
Routine physical exams	$20 co-pay*	Not covered
Immunizations	$0*	Not covered
Professional Services
Office visits	$20 co-pay*	50%
Alternative care ($1,000 per plan year limit) Chiropractic, naturopathic and acupuncture	$20 co-pay*	50%
Maternity
All pre/post office visits and doctor delivery; hospital charges	30%	50%
Hospital Services
Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care	30%	50%
Emergency Services
Urgent Care	$20* co-pay	50%
Hospital emergency room (deductible applies)	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	$15 generics or 50% brand*; $5,000 annual maximum
Accident benefit	Deductible waived for treatment completed within 90 days
*The plan deductible is waived for these services. (The deductibles, co-payments and co-insurance percentages above represent what you pay.)

Note: This is a benefit summary only. For a complete description of benefits, refer to your Policy.