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Index | Exclusions | Provider Directory | ApplicationPlan Benefits:
Optimum Benefits | Value Benefits | Prime Benefits | HSA Benefits
Plan Rates:
Optimum Rates | Value Rates | Prime Rates | HSA Rates
Oregon Medical Insurance > Providence Health Plans > HSA Plan Benefits
HSA Plan |
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| Annual Deductible Individual/Family |
$3,500/$7,000 |
|
| Annual Out-of-Pocket Maximum Individual/Family |
$5,250/$10,500 |
|
| Lifetime Maximum | $2 million per person |
|
| Accidental Injury Benefit | Does not apply |
|
After meeting your deductible, you pay the following
amounts for covered services: (The deductible is waived for some covered services. These services are marked with †. |
||
| Preventive Care |
In-Plan |
Out-of-Plan |
|
Physician/Provider Services |
||
| Office visits to a personal physician/provider | $20 per visit |
40% |
Periodic health exams, well-baby care |
$20 copay † |
40% |
| Office visits to all other physicians/providers | 20% |
40% |
| Routine immunizations/shots | $20 per visit † |
40% |
| Alergy shots; serums; injectable medications | 20% |
40%
|
| Inpatient hospital visits | 20% |
40% |
| Surgery; anesthesia | 20% |
40% |
| Women's Health Services | ||
| Women's annual gynecological exam | $20 per visit † |
40% |
| Follow-up visits after annual gynecological exam | $20 per visit |
40% |
| Mammograms | $20 † |
40% |
| Hospital Services | ||
| Inpatient care | 20% |
40% |
| Observation care | 20% |
40% |
| Rehabilitative care (30 days per calendar year) |
20% |
40% |
| Skilled nursing facility (60 days per calendar year) |
20% |
40% |
| Maternity Care | ||
| Prenatal and postnatal visits; delivery | 20% |
40% |
| Routine newborn nursery care | 20% |
40% |
| Hospital services |
20% |
40% |
| Emergency/Urgent care | ||
| Emergency services |
$250 |
|
| Urgent care services |
$20 per visit |
|
| Emergency transportation services ($2,000 per calendar year) |
20% |
|
| Other Covered Services | ||
| Medical Supplies, including Diabetes Supplies |
20% (deductible does not apply to purchase of diabetic supplies) |
40% |
| Durable medical equipment, Appliances and Prosthetic Devices (limited to $2,500 per calendar year, removable custom shoe orthotics limited to $200 per calendar year) |
20% |
40% |
| X-ray; Lab services | 20% |
40% |
| Imaging services (PET, CT, MRI) | 20% |
40% |
| Outpatient rehabilitative services (30 visits per calendar year) |
20% |
40% |
| Outpatient surgery, dialysis; infusion; chemotherapy; radiation therapy | 20% |
40% |
| Home health care (180 visits per calendar year) |
20% |
40% |
| Hospice care | 20% |
40% |
Self-administered chemotherapy
|
$10 $50 $100 |
Not covered Not covered Not covered |
Mental health Alcohol treatment Prior authorizations is required for all Mental Health and Alcohol Dependency treatment |
20% |
40% |
| Prescription Drugs | ||
| Covered at participating pharmacies at the In-Plan benefit only | Generic and brand-name drugs (up to a 30-day supply) - 50% | |
| A 90-day supply of certain maintenance drugs may be purchased at a participating mail order pharmacy. | ||
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