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Oregon Medical Insurance > ODS Health Plans of Oregon > Beneficial Rx Benefits


HealthNet Health Plans

 
Beneficial Rx (PPO)
Lifetime benefit maximum
$2,000,000
($250,000 can be accessed out of network)
Plan year deductible, individual
(family is 3x the individual)
$1,000 / $2,500 / $5,000
Out-of-pocket maximum, per person
(after deductible)
$3,000
 $6,000
Preventive Care
Member Responsibility
 
In-Network
Out-of-Network
Annual women's exam - pap, pelvic, breast
$15 co-pay*
40%
Women's routine mammogram
$15 co-pay*
40%
Well-baby care
$15 co-pay*
 Not covered
Routine physical exams
$15 co-pay*
Not covered
Immunizations
$0*
Not covered
Professional Services
Office visits
First 3 at $15 **
40%
Alternative care ($1,000 per plan year limit)
Chiropractic, naturopathic and acupuncture
First 3 at $15 **
 40%
Maternity
All pre/post office visits and doctor delivery; hospital charges
20%
40%
Hospital Services
Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care
20%
40%
Emergency Services
Urgent Care
First 3 at $15 **
 40%
Hospital emergency room
(deductible applies)
20% after $100 copayment
40% after $100 copayment
Ambulance
20%
Other Facilities and Services
Lab and X-ray services, rehabilitation services, medical supplies and devices; in-hospital care; home healthcare
20%
40%
Prescription services
$15 generics or 50% brand*; $5,000 annual maximum
Accident benefit Deductible waived for treatment completed within 90 days
*The plan deductible is waived for these services.
**The Beneficial and Beneficial Rx plans pay the first three office visits with a $15 co-payment, which may be used for either illness and injury visits or the preventive care exam.  Alternative care includes an additional three visits with a $15 co-payment. Thereafter, the deductible and co-insurance applies to the benefit maximum.
Fixed dollar copayments, out-of-pocket expenses for prescription drugs and disallowed charges do not apply to the annual deductible or to the out-of-pocket maximum. Expenses applied toward the annual deductible do not aply to the out-of-pocket maximum. Expenses for transplants performed at non-participating transplant facilities and service authorization cost containment penalty do not apply to the out-of-pocket maximum.
Note: This is a benefit summary only. For a complete description of benefits, refer to your Policy.

 

 
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