| |
Maximizer (PPO) |
Plan year deductible
(family deductible is 3x the individual) |
$1,000 / $2,500 / $5,000 |
Out-of-Pocket Maximum, per person
(after deductible) |
$5,000 |
$10,000 |
| Preventive Care |
Member Responsibility |
In Network |
Out of Network |
| Annual women's exam - pap, pelvic, breast |
$20 co-pay* |
50% |
| Women's routine mammogram |
$20 co-pay* |
50% |
| Well-baby care |
$20 co-pay* |
Not covered |
| Routine physical exams |
$20 co-pay* |
Not covered |
| Immunizations |
$0 co-pay* |
Not covered |
| Professional Services |
| Office Visits |
$20 co-pay* |
50% |
Alternative care ($1,000 per plan year
limit)
Chiropractic, naturopathic and acupuncture |
$20 co-pay* |
50% |
| Facility and Ancillary Services |
| Hospital - Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care |
30% |
50% |
| Maternity - All pre/post office visits and doctor delivery; hospital charges |
30% |
50% |
| Mental Health ($2,500 maximum in a 12-month period)Inpatient, outpatient, residential combined |
30% |
50% |
| Lab and X-ray services; rehabilitation services; medical supplies and devices; in-hospital care; home healthcare |
30% |
50% |
| Emergency Services |
| Urgent Care |
$20 co-pay* |
50% |
| Emergency room (deductible applies) |
30% after $100 copay
|
| Ambulance ($5,000 per plan year limit) |
30% |
| Other Benefits |
| Prescription services |
$15 generics or 50% brand*;
$5,000 annual maximum benefit |
| Lifetime benefit maximum |
$2,000,000 |
$250,000 |
| Accident benefit |
Deductible waived for treatment completed
within 90 days of accident. |
| *Deductible waived |
HealthNet
Oregon 
