| |
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% † |
HealthNet
Oregon 
