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Oregon Medical Insurance > Providence Health Plans > Optimum Plan Benefits


 
Optimum Plans
Annual Deductible
Individual/Family
Optimum 1000 - $1,000/$3,000
Optimum 2500 - $2,500/$7,500
Optimum 5000 - $5,000/$15,000
Optimum 10000 - $10,000/$30,000
Annual Out-of-Pocket Maximum
Individual/Family
$4,000/$12,000
Essential Health Benefit Maximum
$1,250,000 plan year aggregate limit
Accidental Injury Benefit The deductible is waived for all covered services, except for chiropractic services, required to treat an accidental injury within 90 days of injury.
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
Covered in full †
40% †
Routine immunizations/shots
Covered in full †
40% †
Mammograms
Covered in full †
40% †
Gynecological exams, Pap tests
Covered in full †
40% †
Physician/Provider Services
Office visits
$20 copay †
40% †
Office visits to specialists
$20 copay †
40% †
Inpatient hospital visits, surgery and anesthesia
20%
40%
Hospital Services
Inpatient & observation care
20%
40%
Maternity care
20%
40%
Routine newborn nursery care
20%
40%
Rehabilitative care
20%
40%
Emergency/Urgent care
Emergency services
$250 copay
Urgent care visits
$20 copay †
40% †
Emergency transportation
20%
20%
Outpatient Diagnostic Services
X-ray; lab services
20%
40%
Imaging services (PET, CT, MRI)
20%
40%
Other Covered Services
Medical & diabetes supplies
20%
40%
Outpatient surgery, radiation therapy, chemotherapy
20%
40%
Mental health and alcohol treatment
20%
40%
Prescription Drugs
Covered at participating retail and mail-order pharmacies only
Generic drugs - $10 †
Brand-name drugs - 50% †
Alternative care services
Acupuncture, chiropractic care, massage therapy and dietitian services
Receive 25% off provider rates through the Choose Healthy network.
Routine Vision Services (administerd by VSP)
Routine Vision Exam
(covered once per 12 months)
$30 copay
Covered up to $29
Frames
(covered once per 24 months)
Covered up to $120
Covered up to $33
Basic Lenses (covered once per 24 months)
Single
Covered in full
Covered up to $28
Bifocal
Covered in full
Covered up to $42
Trifocal
Covered in full
Covered up to $56
Contact Lenses
(covered once per 24 months in lieu of complete pair of glassess)
Covered up to $120
Covered up to $65
Extra Discounts and Savings:

Contacts: 15 percent off cost of contact lens exam (fitting and evaluation)

Laser Vision Correction: Average 15 percent off regular price or 5 percent off promotional price from contracted facilities.
Out-of-plan Vision Services: You get the best value from your benefit when you see a VSP doctor. If you see a non-VSP provider, you’ll typically pay more out-of-pocket. You will pay the provider in full and then have 6 months to submit a claim to VSP for partial reimbursement less copays.

 

 

 

 

 
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