HSA Oregon: Health Savings Accounts in Oregon

HealthNet Crystal HDHP 100% Benefits

Apply Online Now - Electronic Application

	Crystal HDHP 100% Plans
	In-Network	Out of Network
Deductible Choices The deductible Coverage Year (CY) is January 1 through December 31	Individual: $2,000, or $5,000 ⁽¹⁾	Individual: $4,000, or $10,000 ⁽¹⁾
	Family: $4,000, or $10,000⁽¹⁾	Family: $8,000, or $20,000 ⁽¹⁾
Lifetime maximum	$2,000,000 combined
Out-of-pocket maximum (OPM)
Individual	Same as deductible ⁽²⁾	2 x deductible ⁽²⁾
Family	Same as deductible ⁽²⁾	2 x deductible ⁽²⁾
Professional Services
Office visit	No charge	50% UCR+
Well Baby Care (8 exams in the first 24 months) ⁽⁶⁾	No charge	50% UCR+
Annual OB/GYN exam (breast and pelvic exams, cervical cancer screening & mammography) ⁽⁶⁾	No charge	50% UCR+
X-ray and laboratory procedures	No charge	50% UCR+
Outpatient Services
Outpatient or ambulatory care center	No charge	50% UCR+
Outpatient rehabilitation therapy ($2,500/year max)	No charge	50% UCR+
Outpatient facility services (other than surgery)	No charge	50% UCR+
Maternity care
Physicians services for maternity care	No charge	50% UCR+
Hospitalization services
Inpatient hospital care	No charge	50% UCR+
Skilled nursing facility care (60 days per year max)	No charge	50% UCR+
Inpatient rehabilitation therapy (30 days per year max)	No charge	50% UCR+
Emergency health coverage
Outpatient emergency room services	No charge	50% UCR+
Inpatient admission from emergency room	No charge	50% UCR+
Emergency ambulance (up to $3,000 per year)	No charge	No charge UCR+
Additional Accident
Accidental injury deductible waiver **	Not included
Prescription Benefit*** Subject to medical deductible	In Pharmacy (Per Fill Up to a 30-day Supply)	Mail Order (Per Fill Up to a 90-day Supply)
Tier 1 drug list	No charge	No charge
Tier 2 drug list	No charge	No charge
Tier 3 & Specialty	You pay 100%***
Preventive benefits
Routine physical, prostate screening, vision screening	Included
Notes: (1) The deductible must be met each calendar year (January 1 through December 31) before Health Net pays any claims. With this plan, the deductible applies to the annual out-of-pocket maximum. Family coverage means the subscriber and spouse; the subscriber and child(ren); or the subscriber, spouse and child(ren). Under family coverage, each member’s covered expenses count toward the deductible, but the specified family coverage deductible must be met before Health Net pays any claims. (2) The annual out-of-pocket maximum (OPM) is included the annual deductible. (6) The CY deductible is waived PRESCRIPTION DRUG PROGRAM *** In Pharmacy: Prescription drugs may be filled at a participating pharmacy (up to a 30-day supply). Mail Order: Prescription drugs may be filled through our participating mail pharmacy (up to a 90-day supply). When Tier 3 brand name drugs are not covered, members will still have the advantage of Health Net's pharmacy discounts.. Refer to your contract for details, limitations and exclusions.