Oregon Medical Insurance Pool Plan 1500 Benefits

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Oregon Medical Insurance > Oregon Medical Insurance Pool - OMIP > Plan 1500 Benefits

	Medical & Portability Plan 1500 Benefit Summary
Lifetime Maximum Benefit	$2,000,000
Pre-existing Waiting Period, Including Pregnancy	Medical eligibility - 6 months/Portability - No waitng period
	In Network you pay	Out of Network you pay
Annual Prescription Deductible	$1,000
Annual Medical Deductible	$1,500
Maximum Annual Medical Out of Pocket, excluding medical deductible, per individual¹	$6,000	$12,000
Doctor Visits	30%	50%
Hospital	30%	50%
Outpatient Surgery	30%	50%
Skilled Nursing Care - limited to 60 days	30%
Home Health Care - limited to 60 visits	30%	50%
Emergency Room²	30% + $100 copay	30% + $100 copay
Ambulance	30%
Maternity	30%	50%
Diagnostic X-Ray/Lab	30%	50%
Transplant²	0%	50%
Hospice	30%	50%
Rehabilitation Inpatient - limited to 60 days	30%	50%
Rehabilitation Outpatient - limited to 60 days	30%	50%
Durable Medical Equipment	30%
Mental Health	30%	50%
Chemical Dependency	30%	50%
Womens Health Care Services³	20%	Not Covered
Mens Health Care Services³	20%	Not Covered
Immunizations³	20%	Not Covered
Well Baby Care³	20%	Not Covered
Well Child Care³	20%	Not Covered
Prescription Drugs: No out of pocket maximum on prescription drugs² & $1,000 Rx deductible (annual)
Generic Coinsurance⁴	up to $5
Preferred Brand Coinsurance⁴	up to $40
Non-Prefered Brand Coinsurance	up to $70
1) This is the maximum amount you will pay for covered medical services per individual, per calendar year, excluding the deductibles, before OMIP will begin paying 100% for covered services. 2) The emergency room co-pay, out-of-pocket prescription drug payments, transplants performed at noncontracting facilities, and disallowed charges do not apply to the medical deductible or out-of-pocket maximum. 3) These services do NOT accumulate towards the maximum annual out-of-pocket expense. Also, you do not have to meet the annual medical deductible before OMIP pays for these services. Adult (age 19 and above) immunizations are limited to the following: Influenza (flu), Zostavax (shingles), Pneumococcal (pneumonia), Tetanus/Diphtheria Toxoid, and Varicella (chicken pox). 4) $0 co-payment for specific diabetic supplies, insulin (excluding pumps), and evidence-based generic maintenance medications as determined by OMIP. A list of these medications can be found on our Web site at www.omip.state.or.us. Not subject to Rx deductible for Plan 1500. This list is subject to change. This Health Benefit Plan Summary is intended only as a brief summary of our benefit plans. Please refer to the OMIP Contract for specific details. Exact terms, conditions, provisions, exclusions, and limitations are defined in the OMIP contract.

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Oregon Medical Insurance > Oregon Medical Insurance Pool - OMIP > Plan 1500 Benefits