HSA Oregon: Health Savings Accounts in Oregon

Providence HSA Plan Benefits

	HSA Plans
Annual Deductible Individual deductible/Family Deductible	HSA 1200 - $1,200/$2,400 HSA 2500 - $2,500/$5,000
Annual Out-of-Pocket Maximum Individual out-of-pocket maximum/ Family out-of-pocket maximum	HSA 1200 - $5,250/$10,500 HSA 2500 - $5,000/$10,000
Lifetime Maximum	$2 million per person
Accidental Injury Benefit	Does not apply
*After meeting your deductible, you pay the following amounts for covered services:* (The deductible is waived for some covered services. These services are marked with †.
Preventive Care	In-Plan	Out-of-Plan
Periodic health exams, well-baby care	$20 copay †	40%
Women's annual gynecological exam	$20 copay †	40%
Follow-up visits after annual gynecological exam	$20 copay †	40%
Mammograms	$20 copay †	40%
Physician/Provider Services
Office visits to a personal physician/provider	$20 copay	40%
Office visits to a chiropractor (limited to 15 visits per calendar year)	$20 copay	Not Covered
Office visits to specialists	20%	40%
Other services, including inpatient hospital visits	20%	40%
Routine immunizations/shots	$20 copay †	40%
Hospital Services
Acute care	20%	40%
Skilled nursing facility (see limitations)	20%	40%
Maternity Care
Provider & hospital services	20%	40%
Emergent/Urgent care
Emergency services	$125
Urgent care services	20%
Ambulance services (see limitations)	20%
Other Covered Services
Durable medical equipment & medical supplies (see limitations)	20%	40%
Outpatient rehabilitative services (see limitations)	20%	40%
Laboratory & x-ray Outpatient surgery, Radiation therapy, Chemotherapy	20%	40%
Home health care (see limitations)	20%	40%
Mental health and alcohol treatment (see limitations)	20%	40%
Prescription Drugs
Covered at participating pharmacies at the In-Plan benefit only	Generic and brand-name drugs (up to a 30-day supply) - 50%
	A 90-day supply of certain maintenance drugs may be purchased at a participating mail order pharmacy.