ODS HSA 3000 PPO Benefits

Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994

	HSA 3000
Standard HSA Plan	In Network	Out of Network
Plan year deductible	$3,000 (individual) / $6,000 (family)
Plan Year Out-of-Pocket Maximum for Services Other Than Preventive Care	$0	No maximum
Plan Year Out-of-Pocket Maximum for Preventive Care Services Only	$2,000 (Individual) / $4,000 (Family)	No maximum
Preventive Care
Annual women's exam - pap, pelvic, breast	50%*	50%
Women's routine mammogram	50%*	50%
Well-baby care	50%*	50%
Routine physical exams	50%*	50%
Immunizations	50%*	50%
Professional Services
Office Visits	0%	50%
Alternative care ($1,000 per plan year limit) Chiropractic, naturopathic and acupuncture	0%	50%
Facility and Ancillary Services
Hospital - Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care	0%	50%
Maternity - All pre/post office visits and doctor delivery; hospital charges	0%	50%
Mental Health ($2,500 maximum in a 12-month period)Inpatient, outpatient, residential combined	0%	50%
Lab and X-ray services; rehabilitation services; medical supplies and devices; in-hospital care; home healthcare	0%	50%
Emergency Services
Urgent Care	0%	50%
Emergency room (deductible applies)	0%	50%
Ambulance ($5,000 per plan year limit)	0%
Other Benefits
Prescription services	0%
Lifetime benefit maximum	$2,000,000	$250,000
Accident benefit	Paid as any other illness subject to deductible/co-insurance
*The plan deductible is waived for these services.

Note: This is a benefit summary only. For a complete description of benefits, refer to your Policy.