Providence Health Plans for Oregon HSA Plan Benefits

Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994

Oregon Medical Insurance > Providence Health Plans > HSA Plan Benefits

	HSA 2500		HSA 3500
Annual Deductible Individual/Family	$2,500/$5,000		$3,500/$7,000
Annual Out-of-Pocket Maximum Individual/Family	$5,000/$10,000		$5,950/$11,900
Essential Health Benefit Maximum	$1,250,000 plan year aggregate limit		$1,250,000 plan year aggregate limit
Accidental Injury Benefit	Does not apply		Does not apply
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 †.
	In-Plan	Out-of-Plan	In-Plan	Out-of-Plan
Preventive Care
Periodic health exams, well-baby care	Covered in full †	40%	Covered in full †	50%
Routine immunizations/shots	Covered in full †	40%	Covered in full †	50%
Mammograms	Covered in full †	40%	Covered in full †	50%
Gynecological exams, Pap tests	Covered in full †	40%	Covered in full †	50%
Physician/Provider Services
Office visits	$20 copay	40%	50%	50%
Office visits to specialists	20%	40%	50%	50%
Inpatient hospital visits, surgery, anesthesia	20%	40%	50%	50%
Hospital Services
Inpatient and observation care	20%	40%	50%	50%
Maternity care	20%	40%	50%	50%
Routine newborn nursery care	20%	40%	50%	50%
Rehabilitative care	20%	40%	50%	50%
Emergency/Urgent care
Emergency services	$250 copay		50%	50%
Urgent care services	$20 copay	40%	50%	50%
Emergency transportation	20%	20%	50%	50%
Outpatient Diagnostic Services
X-ray; lab services	20%	40%	50%	50%
Imaging services (PET, CT, MRI)	20%	40%	50%	50%
Other Covered Services
Medical & Diabetes Supplies	20%	40%	50%	50%
Outpatient surgery, radiation therapy, chemotherapy	20%	40%	50%	50%
Mental health & alcohol treatment	20%	40%	50%	50%
Prescription Drugs
Covered at participating retail and mail-order pharmacies only	Generic and brand-name drugs (up to a 30-day supply) - 50%
Alternative care services
Acupuncture, chiropractic care, massage therapy and dietitian services	Receive 25% off provider rates through the Choose Healthy network.

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Oregon Medical Insurance > Providence Health Plans > HSA Plan Benefits