ODS Maximizer PPO Benefits

Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994

	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
Preventive Care	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

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