Providence Health Plans of Oregon

Providence HSA Benefits
  HSA 2500 HSA 3500
Annual Deductible
Individual/Family		 $2,500/$5,000 $3,500/$7,000
Annual Out-of-Pocket Maximum
Individual/Family		 $5,000/$10,000 $5,950/$11,900
Essential Health Benefit Maximum $1,250,000 plan year aggregate limit $1,250,000 plan year aggregate limit
Accidental Injury Benefit Does not apply 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 †.
  In-Plan Out-of-Plan In-Plan Out-of-Plan
Preventive Care
Periodic health exams, well-baby care Covered in full † 40% Covered in full † 50%
Routine immunizations/shots Covered in full † 40% Covered in full † 50%
Mammograms Covered in full † 40% Covered in full † 50%
Gynecological exams, Pap tests Covered in full † 40% Covered in full † 50%
Physician/Provider Services
Office visits $20 copay 40% 50% 50%
Office visits to specialists 20% 40% 50% 50%
Inpatient hospital visits, surgery, anesthesia 20% 40% 50% 50%
Hospital Services
Inpatient and observation care 20% 40% 50% 50%
Maternity care 20% 40% 50% 50%
Routine newborn nursery care 20% 40% 50% 50%
Rehabilitative care 20% 40% 50% 50%
Emergency/Urgent care
Emergency services $250 copay 50% 50%
Urgent care services $20 copay 40% 50% 50%
Emergency transportation 20% 20% 50% 50%
Outpatient Diagnostic Services
X-ray; lab services 20% 40% 50% 50%
Imaging services (PET, CT, MRI) 20% 40% 50% 50%
Other Covered Services
Medical & Diabetes Supplies 20% 40% 50% 50%
Outpatient surgery, radiation therapy, chemotherapy 20% 40% 50% 50%

Mental health & alcohol treatment

 20% 40% 50% 50%
Prescription Drugs
Covered at participating retail and mail-order pharmacies only Generic and brand-name drugs (up to a 30-day supply) - 50%
Alternative care services
Acupuncture, chiropractic care, massage therapy and dietitian services Receive 25% off provider rates through the Choose Healthy network.