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Index | Exclusions
| Providers
| Application
Plan Benefits:
Optimum Benefits | Value Benefits | HSA Benefits
Plan Rates:
Optimum Rates | Value Rates | HSA Rates
Plan Benefits:
Optimum Benefits | Value Benefits | HSA Benefits
Plan Rates:
Optimum Rates | Value Rates | HSA Rates
Oregon Medical Insurance > Providence Health Plans > Optimum Plan Benefits
Optimum Plans |
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| Annual Deductible Individual deductible/Family Deductible |
Optimum 500 - $500/$1,500 |
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Optimum 1000 - $1,000/$3,000 |
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Optimum 2500 - $2,500/$7,500 |
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Optimum 5000 - $5,000/$15,000 |
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Optimum 10000 - $10,000/$30,000 |
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| Annual Out-of-Pocket Maximum Individual out-of-pocket maximum/ Family out-of-pocket maximum |
$2,500/$7,500 |
|
| Lifetime Maximum | $2 million per person (up to $25,000 of total amount of benefits paid will be restored to Lifetime Maximum every calendar year) |
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| 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. | |
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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 †. |
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| Preventive Care |
In-Plan |
Out-of-Plan |
| Periodic health exams, well-baby care |
$20 copay† |
40% † |
| Women's annual gynecological exam |
$20 copay † |
40% † |
| Follow-up visits after annual gynecological exam |
$20 copay † |
40% † |
| Mammograms |
$20 copay † |
40% † |
|
Physician/Provider Services |
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| Office visits to a personal physician/provider | $20 copay † |
40% † |
| Office visits to specialists |
$20 copay † |
40% † |
| Other services, including inpatient hospital visits |
20% |
40% |
| Routine immunizations/shots |
$20 copay † |
40% † |
| Hospital Services | ||
| Acute care |
20% |
40% |
| Skilled nursing facility |
20% |
40% |
| Maternity Care | ||
| Provider & hospital services |
20% |
40% |
| Emergent/Urgent care | ||
| Emergency services |
$125 copay |
|
| Urgent care services |
20% † |
|
| Ambulance services (see limitations) |
20% |
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| Other Covered Services | ||
| Durable medical equipment & medical supplies (see limitations) |
20% |
40% |
| Rehabilitative care & services (see limitations) |
20% |
40% |
| Laboratory & x-ray Outpatient surgery, Radiation therapy, Chemotherapy |
20% |
40% |
| Home health care (see limitations) |
20% |
40% |
| Mental health and alcohol treatment (see limitations) |
20% |
40% |
| Prescription Drugs | ||
| Covered at participating retail and mail-order pharmacies only | Generic drugs - $10 † Brand-name drugs (up to a 30-day supply) - 50% † |
|
| A 90-day supply of certain maintenance drugs may be purchased at a participating mail order pharmacy. | ||
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