HSA Oregon: Health Savings Accounts in Oregon

HealthNet Crystal HDHP 80% Benefits

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	Crystal HDHP 80% Plans
	In-Network	Out of Network
Deductible Choices The deductible Coverage Year (CY) is January 1 through December 31	Individual: $1,500, $2,500, or $3,500 ⁽¹⁾	Individual: $3,000, $5,000, or $,7000 ⁽¹⁾
	Family: $3,000, $5,000, or $7,000 ⁽¹⁾	Family: $6,000, $10,000 or $14,000 ⁽¹⁾
Lifetime maximum	$2,000,000 combined
Out-of-pocket maximum (OPM)
Individual	$5,000 ⁽²⁾	$15,000 ⁽²⁾
Family	$10,000 ⁽²⁾	$30,000 ⁽²⁾
Professional Services
Office visit	20%	50% UCR+
Well Baby Care (8 exams in the first 24 months) ⁽⁶⁾	20%	50% UCR+
Annual OB/GYN exam (breast and pelvic exams, cervical cancer screening & mammography) ⁽⁶⁾	20%	50% UCR+
X-ray and laboratory procedures	20%	50% UCR+
Outpatient Services
Outpatient or ambulatory care center	20%	50% UCR+
Outpatient rehabilitation therapy ($2,500/year max)	20%	50% UCR+
Outpatient facility services (other than surgery)	20%	50% UCR+
Maternity care
Physicians services for maternity care	20%	50% UCR+
Hospitalization services
Inpatient hospital care	20%	50% UCR+
Skilled nursing facility care (60 days per year max)	20%	50% UCR+
Inpatient rehabilitation therapy (30 days per year max)	20%	50% UCR+
Emergency health coverage
Outpatient emergency room services	20%	50% UCR+
Inpatient admission from emergency room	20%	50% UCR+
Emergency ambulance (up to $3,000 per year)	20%	20% 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	50%	50%
Tier 2 drug list	50%	50%
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. 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.