Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994
Apply Online Now - Electronic Application
Index | Dental Plan | Exclusions
& Limitations | Locate
Providers | Application
Plan Benefits:
Diamond 15 | Pearl 25 HMO
| Emerald 40 | Garnet 50 | Topaz | Crystal 80 HDHP | Crystal 100 HDHP
Plan Rates:
Diamond 15 | Pearl 25 HMO | Emerald 40 | Garnet 50 | Topaz | Crystal 80 HDHP | Crystal 100 HDHP
Oregon Medical Insurance > HealthNet of Oregon > Pearl 25 HMO Benefits
| Benefits Coodinated by your PCP |
Pearl 25 HMO
|
|
| Deductible Choices The deductible Coverage Year (CY) is January 1 through December 31 |
No Deductible
|
|
| Out-of-pocket maximum (OPM) | ||
|
$4,000 single (3)
|
|
|
$12,000 family (3)
|
|
| Lifetime maximum |
Unlimited
|
|
| Professional Services | ||
| Office visit |
$25
|
|
| Well Baby Care (8 exams in the first 24 months) |
$25
|
|
| Annual OB/GYN exam (breast and pelvic exams, cervical cancer screening & mammography) |
$25
|
|
| X-ray and laboratory procedures |
$25
|
|
| Outpatient Services | ||
| Outpatient or ambulatory care center |
$250
|
|
| Outpatient rehabilitation therapy |
$10
($2,500/year max) |
|
| Outpatient facility services (other than surgery) |
$250
|
|
| Maternity care (Physicians services for maternity care) |
$250 per pregnancy
|
|
| Hospitalization services | ||
| Inpatient hospital care |
$400 per day
(until OPM met) |
|
| Skilled nursing facility care (60 days/year max) |
No charge
|
|
| Inpatient rehabilitation therapy (30 days/year max) |
$400 per day
|
|
| Emergency services | ||
| Outpatient emergency room services |
$100 per visit
(waived if admitted) |
|
| Inpatient admission from emergency room |
$400 per day
|
|
| Emergency ambulance transport - $3,000/year max |
20% (UCR plus applies to Out-of-Network providers)
|
|
| Additional Accident | ||
| Accidental injury deductible waiver ** |
No deductible
|
|
| Prescription Benefit Calendar Year Deductible for Rx Benefits: $100 per Member Maximum Rx Benefit: $4,000 per Member per Calendar Year |
In Pharmacy
(Per Fill Up to a 30-day Supply) |
Mail Order
(Per Fill Up to a 90-day Supply) |
|
50%
|
50%
|
|
50%
|
50%
|
|
You pay the full cost of the prescription at Health
Net’s discounted rate.
|
You pay the full cost of the prescription at Health
Net’s discounted rate.
|
| Preventive benefits | ||
| Routine physical, prostate screening, vision screening |
Preventive included
|
|
| Well Net Complementary Care $500 annual benefit |
Well Net Included
|
|
| Chiro, acupuncture, naturopathy |
$20 copay
|
|
| Massage therapy |
$25 copay / 9 visits
|
|
|
Notes: You do not have to pay a deductible for medical coverage on the HMO plan. Prescription drug coverage has a deductible and annual maximum. Your benefits are subject to copayments listed in this schedule. You must select a Primary Care Provider (PCP) from our HMO network. Your PCP coordinates all your health care, including referrals. Certain services are covered only if provided by a designated Specialty Care provider. 3) After you reach the OPM copayment maximum in a Calendar Year, we will pay your covered HMO services during the rest of that Calendar Year at 100% of our HMO contract rates. PRESCRIPTION DRUG PROGRAM
Refer to your contract for details, limitations and exclusions. |
||