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Local Phone: 503-813-2000
Toll-Free Phone: 1-800-813-2000
TTY/TDD Phone: 1-800-735-2900
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Benefit Summary
| Annual Costs | 2010 Coverage |
|---|---|
Annual deductible |
$0 |
Annual out-of-pocket maximum |
$1,500/person |
Annual prescription drug deductible |
Does not apply |
| Medical Benefits | 2010 Coverage |
|---|---|
Ambulance services |
|
(air) |
$100/trip |
(ground) |
$100/trip |
Diagnostic tests, laboratory, and X-rays |
$10 |
Durable medical equipment, supplies, and prostheses |
20% |
Emergency room (copay waived if admitted) |
$75 |
Hearing |
|
(routine annual exam) |
$20 |
(hardware) |
Enrollee pays any costs above $800, allowed every 36 months for hearing aid and rental/repair combined |
Hospital services |
|
(inpatient) |
$200/day ($1,000 max/ admission) |
(outpatient) |
$100 |
Mental health care |
|
(outpatient) |
$20 |
Obstetric care |
|
(inpatient) |
$200/day ($1000 max/admission) |
(outpatient) |
Enrollee pays $0 |
Office visits |
$20 primary care; $30 specialty care; $40 urgent care |
Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined) |
$30 |
Prescriptions |
|
tier 1 (retail pharmacy, 30-day supply) |
$15 |
tier 2 (retail pharmacy, 30-day supply) |
$30 |
tier 3 (retail pharmacy, 30-day supply) |
N/A |
tier 1 (mail order, 90-day supply) |
$30 |
tier 2 (mail order, 90-day supply) |
$60 |
tier 3 (mail order, 90-day supply) |
N/A |
Preventive care |
Enrollee pays $0 (See Certificate of Coverage or check with plan for full list of services) |
Spinal manipulations (per-visit cost for 10 visits/year) |
$30 |
Vision care |
|
(annual exam) |
$20 |
(glasses and contact lenses) |
Enrollee pays any costs above $150 every 24 months for frames, lenses, contacts, and fitting fees combined. |
