|
Plan Summaries table
|
Benefit
|
Open Value
|
Open Value w/Rx
|
Open Premier
|
Open Premier w/Rx
|
|
Mo Premium
|
$0
|
$0
|
$70
|
$132
|
|
Dr visit
|
$15 copay
|
$15 copay
|
$0 copay
|
$0 copay
|
|
Maxium
Out-of-Pocket
|
$3,000
|
$3,000
|
$1,000
|
$1,000
|
|
Rx Copays
|
N/A
|
$225 ded on brand names
4/11/24
|
N/A
|
$0 ded
0/10/35
|
|
Specialist visit
|
$15 copay
|
$15 copay
|
$0 copay
|
$0 copay
|
|
Inpatient
Hospital
|
Days 1-7,
copay $150
per day
$0 for additional days
|
Days 1-7,
copay $150
per day
$0 for additional days
|
$0 copay
|
$0 copay
|
|
Outpatient
Hospital
|
$150 copay
|
$150 copay
|
$0 copay
|
$0 copay
|
|
Emergency
Care
|
$50 copay
|
$50 copay
|
$0 copay
|
$0 copay
|
|
Ambulance
Services
|
$100 copay
|
$100 copay
|
$50 copay
|
$50 copay
|
|
Vision
|
$0 copay 1 routine
exam every year.
$125 limit for eyewear every two yrs |
Oregon counties: Clackamas, Columbia, Hood River*, Marion, Multnomah, Polk, Washington.
Washington counties: Clark, Kitsap, Thurston
*Monthly premium varies for plans in this county
|
