Oregon Medical Insurance Pool Plan 500 Benefits

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Oregon Medical Insurance > Oregon Medical Insurance Pool - OMIP > Plan 500 Benefits

	Medical Plan 500 Benefit Summary
Lifetime Maximum Benefit	$2,000,000
Pre-existing Waiting Period, Including Pregnancy	6 months
	In Network you pay	Out of Network you pay
Annual Medical Deductible	$500
Maximum Annual Medical Out of Pocket, excluding medical deductible, per individual¹	$1,000	$2,000
Doctor Visits	20%	40%
Hospital	20%	40%
Outpatient Surgery	20%	40%
Skilled Nursing Care - limited to 60 days	20%
Home Health Care - limited to 60 visits	20%	40%
Emergency Room²	20% + $100 copay	20% + $100 copay
Ambulance	20%
Maternity	20%	40%
Diagnostic X-Ray/Lab	20%	40%
Transplant²	0%	40%
Hospice	20%	40%
Rehabilitation Inpatient - limited to 60 days	20%	40%
Rehabilitation Outpatient - limited to 60 days	20%	40%
Durable Medical Equipment	20%
Mental Health	20%	40%
Chemical Dependency	20%	40%
Womens Health Care Services³	20%	Not Covered
Mens Health Care Services³	20%	Not Covered
Immunizations³	20%	Not Covered
Well Baby Care³	20%	Not Covered
Well Child Care³	20%	Not Covered
Prescription Drugs: No out of pocket maximum on prescription drugs² & $0 Rx deductible
Generic Coinsurance⁴	up to $5
Preferred Brand Coinsurance⁴	up to $40
Non-Prefered Brand Coinsurance	up to $70
1) This is the maximum amount you will pay for covered medical services per individual, per calendar year, excluding the deductibles, before OMIP will begin paying 100% for covered services. 2) The emergency room co-pay, out-of-pocket prescription drug payments, transplants performed at noncontracting facilities, and disallowed charges do not apply to the medical deductible or out-of-pocket maximum. 3) These services do NOT accumulate towards the maximum annual out-of-pocket expense. Also, you do not have to meet the annual medical deductible before OMIP pays for these services. Adult (age 19 and above) immunizations are limited to the following: Influenza (flu), Zostavax (shingles), Pneumococcal (pneumonia), Tetanus/Diphtheria Toxoid, and Varicella (chicken pox). 4) $0 co-payment for specific diabetic supplies, insulin (excluding pumps), and evidence-based generic maintenance medications as determined by OMIP. A list of these medications can be found on our Web site at www.omip.state.or.us. Not subject to Rx deductible for Plan 1500. This list is subject to change. This Health Benefit Plan Summary is intended only as a brief summary of our benefit plans. Please refer to the OMIP Contract for specific details. Exact terms, conditions, provisions, exclusions, and limitations are defined in the OMIP contract.

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Oregon Medical Insurance > Oregon Medical Insurance Pool - OMIP > Plan 500 Benefits