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Oregon Medical Insurance > Providence Health Plans > Value Plan Benefits

Providence Health Plans

 
Value Plans
Annual Deductible
Individual/Family
Value 500 - $500/$1,500
Value 1000 - $1,000/$3,000
Value 2500 - $2,500/$7,500
Value 5000 - $5,000/$15,000
Value 7500 - $7,500/$22,500
Annual Out-of-Pocket Maximum
Individual/ Family
Value 500 - $4,000/$12,000
Value 1000 - $4,500/$13,500
Value 2500 - $5,500/$16,500
Value 5000 - $8,500/$25,500
Value 7500 - $11,000/$33,000
Lifetime Maximum
$2 million per person
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 †. *Limitations apply. See your Plan Contract for details
Preventive Care
In-Plan
Out-of-Plan
Periodic health exams, well-baby care
$20 copay †
50% †
Annual gynecological exam
$20 copay †
50% †
Routine immunizations/shots
$20 copay †
50%
Mammograms
$20 copay †
50%
Physician/Provider Services
Office visits to a personal physician/provider
$20 copay †
50% †
Office visits to specialists
30%
50%
Inpatient hospital visits, surgery and other services
30%
50%
Hospital Services
Inpatient & observation care
30%
50%
Rehabilitative care & services*
30%
50%
Maternity Care
Provider & hospital services
30%
50%
Emergency/Urgent care
Emergency services
$250 copay
Urgent care services
$20 copay †
Emergency transportation services*
30%
Other Covered Services
Medical & diabetes supplies*
30%
50%
Lab & x-ray, outpatient surgery, radiation therapy, chemotherapy
30%
50%
Home health care*
30%
50%
Mental health and alcohol treatment*
30%
50%
Prescription Drugs
Covered at participating pharmacies at the In-Plan benefit only Generic drugs & Brand-name drugs -50% †
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 $80
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 $80
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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