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.