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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 > Value Plan Benefits
Value Plans |
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| Annual Deductible Individual deductible/Family Deductible |
Value 500 - $500/$1,500 |
|
Value 1000 - $1,000/$3,000 |
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Value 2500 - $2,500/$7,500 |
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Value 5000 - $5,000/$15,000 |
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Value 7500 - $7,500/$22,500 |
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| Annual Out-of-Pocket Maximum Individual out-of-pocket maximum/ Family out-of-pocket maximum |
Value 500 - $4,000/$12,000 |
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Value 1000 - $4,500/$13,500 |
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Value 2500 - $5,500/$16,500 |
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Value 5000 - $8,500/$25,500 |
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Value 7500 - $11,000/$33,000 |
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| 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) |
|
| 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 †. |
||
| Preventive Care |
In-Plan |
Out-of-Plan |
| Periodic health exams, well-baby care | $20 copay † |
50% † |
| Women's annual gynecological exam | $20 copay † |
50% † |
| Follow-up visits after annual gynecological exam | $20 copay † |
50% |
| Mammograms | $20 copay † |
50% |
|
Physician/Provider Services |
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| Office visits to a personal physician/provider |
$20 copay † |
50% † |
| Office visits to specialists |
30% |
50% |
| Other services, including inpatient hospital visits |
30% |
50% |
| Routine immunizations/shots |
$20 copay † |
50% † |
| Hospital Services | ||
| Acute care |
30% |
50% |
| Skilled nursing facility (see limitations) |
30% |
50% |
| Maternity Care | ||
| Provider & hospital services |
30% |
50% |
| Emergent/Urgent care | ||
| Emergency services | $125 copay |
|
| Urgent care services | 30% † |
|
| Ambulance services | 30% |
|
| Other Covered Services | ||
| Durable medical equipment & medical supplies |
30% |
50% |
| Outpatient rehabilitative services |
30% |
50% |
| Laboratory & x-ray Outpatient surgery, Radiation therapy, Chemotherapy |
30% |
50% |
| Home health care |
30% |
50% |
| Mental health and alcohol treatment |
30% |
50% |
| Prescription Drugs | ||
| Covered at participating pharmacies at the In-Plan benefit only | Generic drugs & 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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