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Index | Exclusions
| Providers
| Application
Plan Benefits:
Optimum Benefits | Value Benefits | HSA Benefits
Plan Rates:
Optimum Rates | Value Rates | HSA Rates
Plan Benefits:
Optimum Benefits | Value Benefits | HSA Benefits
Plan Rates:
Optimum Rates | Value Rates | HSA Rates
Oregon Medical Insurance > Providence Health Plans > HSA Plan Benefits
HSA Plans |
||
| Annual Deductible Individual deductible/Family Deductible |
HSA 1200 - $1,200/$2,400 HSA 2500 - $2,500/$5,000 |
|
| Annual Out-of-Pocket Maximum Individual out-of-pocket maximum/ Family out-of-pocket maximum |
HSA 1200 - $5,250/$10,500 HSA 2500 - $5,000/$10,000 |
|
| 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 |
| Periodic health exams, well-baby care | $20 copay † |
40% |
| Women's annual gynecological exam | $20 copay † |
40% |
| Follow-up visits after annual gynecological exam | $20 copay † |
40% |
| Mammograms | $20 copay † |
40% |
|
Physician/Provider Services |
||
| Office visits to a personal physician/provider | $20 copay |
40% |
| Office visits to a chiropractor (limited to 15 visits per calendar year) |
$20 copay |
Not Covered |
| Office visits to specialists | 20% |
40%
|
| Other services, including inpatient hospital visits | 20% |
40% |
| Routine immunizations/shots | $20 copay † |
40% |
| Hospital Services | ||
| Acute care |
20% |
40% |
| Skilled nursing facility (see limitations) |
20% |
40% |
| Maternity Care | ||
| Provider & hospital services |
20% |
40% |
| Emergent/Urgent care | ||
| Emergency services |
$125 |
|
| Urgent care services |
20% |
|
| Ambulance services (see limitations) |
20% |
|
| Other Covered Services | ||
| Durable medical equipment & medical supplies (see limitations) |
20% |
40% |
| Outpatient rehabilitative services (see limitations) |
20% |
40% |
| Laboratory & x-ray Outpatient surgery, Radiation therapy, Chemotherapy |
20% |
40% |
| Home health care (see limitations) |
20% |
40% |
| Mental health and alcohol treatment (see limitations) |
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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