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Oregon Medical Insurance > Providence Health Plans > Prime Plan Benefits

Providence Health Plans

 
Prime Plan
Annual Deductible
Individual/Family
$10,000/$30,000
Annual Out-of-Pocket Maximum
Individual/Family
$7,500/$22,500
Lifetime Maximum
$2 million per person
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.
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 †. *Limitations apply. See your Plan Contract for details
Preventive Care
In-Plan
Out-of-Plan
Periodic health exams, well-baby care
50% †
Not Covered
Annual gynecological exam
50% †
Not Covered
Routine immunizations/shots
50% †
Not Covered
Mammograms
50% †
Not Covered
Physician/Provider Services
Office visits to a personal physician/provider
50% †
Not Covered
Office visits to specialists
50% †
Not Covered
Inpatient hospital visits, surgery and other services
50%
Not Covered
Hospital Services
Inpatient & observation care
50%
Not Covered
Rehabilitative care & services*
50%
Not Covered
Maternity Care
Provider & hospital services
50%
Not Covered
Emergency/Urgent care
Emergency services
50%
Urgent care services
50%
Emergency transportation services*
50%
Other Covered Services
Medical & diabetes supplies*
50%
Not Covered
Lab & x-ray, outpatient surgery, radiation therapy, chemotherapy
50%
Not Covered
Home health care*
50%
Not Covered
Mental health and alcohol treatment*
50%
Not Covered
Prescription Drugs
Covered at participating retail and mail-order pharmacies only Generic drugs - $10 †
Brand-name drugs - 50% †

 

 

 

 

 
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