Oregon School Boards Association Preferred Provider Plan
This chart is a brief summary of your benefits under this plan. Your benefit booklet will give you a more complete description ofyour plan. A copy of this is available from your school district’s group administrator. A special feature of your coverage is its “holdharmless” clause. Basically, this clause guarantees you that participating providers (available on our web site) will not charge youbeyond the fee upon which we base our payment. Of course, any applicable deductible and coinsurance will continue to apply. Providers who are not participating, however, may bill you for any balances over our payment level. All services and suppliesdescribed below must be medically necessary and all payments are based on eligible charges for such services and supplies. Benefit Features Preferred Non-Preferred Provider Benefit Provider Benefit
Individual deductible per calendar year (separate from prescription medications)
Maximum family deductible per calendar year
We pay 90% or 70% of covered expenses up to this amount after the deductible
Your maximum medical out-of-pocket per person per calendar year (10% or
30% coinsurance) including deductibleAfter your maximum medical out-of-pocket is met each calendar year, we pay
Please note: Covered expenses paid at 100% and copayments do not accumulate towards your maximum out-of-pocket. Copayments will continue to be collected after your maximum out-of-pocket has been reached. Preventive Care Services1 (up to $500 per calendar year) Deductible Waived - We Pay
Routine physical exams including related lab and X-ray
Annual women’s exams including Pap and mammogram
Professional Services After Deductible - We Pay
Allergy shots and other therapeutic injections
Outpatient Mental Illness/Chemical Dependency1
Inpatient hospital stay including rehabilitation or mental illness/chemicaldependency1
Emergency room care (copayment waived if admitted)
Rehabilitation including Occupational, Speech, and Physical Therapy1
Additional accident (deductible waived for 90 days from injury date
Outpatient Durable Medical Equipment and Supplies
Non-Preferred Brand Prescription Medications – Retail and Mail Order1 Preferred Brand and Generic Medications Medications
Individual deductible per calendar year (no family maximum)
We pay this percentage of covered expenses
Individual prescription medication out-of-pocket limit per calendar year
including deductible (separate from medical)After your maximum prescription medication out-of-pocket is met each
1Limits may apply, please refer to the Limitations And Exclusions on page 2. Limitations and Exclusions This is a benefit summary only. For a complete list of benefits and the limitations and exclusions that apply to them, please refer to the benefits booklet. Preventive Care Schedule Mental Illness and Chemical Dependency Schedule* Well-baby Care* Children Mental Illness Treatment Setting Immunizations* (Not covered for travel or passport purposes) Physical Exams* Chemical Dependency Treatment Children Women’s Exams
*Per 24 consecutive calendar months and subject to limitations
designated under state and federal law. These Medical Benefits Are Not Covered
¾ Services provided by a member of the patient’s immediate
*Preventive Care services paid 100% up to $500 per calendar year
¾ Charges in excess of the amount allowed according to the
These Pharmacy Benefits Are Limited
¾ Services or supplies that are not medically necessary.
¾ The maximum quantity for pharmacy purchased medications is
¾ Naturopathy, faith healing services, and homeopathy, even
34-day supply at retail pharmacy, 90-day supply through mail
when provided by participating providers.
order. Some medications may be limited by quantity rather
¾ Services related to or supporting infertility, reversal of
sterilization procedures, and impotence medications.
¾ Some medications may require preauthorization by the health
¾ Custodial care, personal hygiene, and other forms of
¾ Compound medications are only covered when one ingredient
is a federal legend or state restricted medication.
¾ Services and supplies provided for obesity or weight
These Pharmacy Benefits are Not Covered
reduction, including complications arising from suchtreatment.
¾ Oral and injectable impotence medications, infertility
¾ Chronic or long-term psychotherapy (defined as services
medications, and experimental/investigational medications.
provided in excess of crisis intervention or short-term
¾ Medications prescribed for cosmetic purposes (including, but
not limited to Retin-A for anyone over 25 years of age,
¾ Services or supplies for the treatment of personality
Renova, Lamisil, Sporanox, and topical minoxidil).
disorders, paraphilia, or other gender identity disorders. These Medical Benefits Are Limited
¾ Cosmetic/reconstructive services and supplies, including
complications arising from such services, except for breast
¾ We provide transplant coverage only to those who have been
reconstruction following a mastectomy necessary due to
covered by us, or another insurer with similar transplant
coverage, for a total of at least 12 months (or since birth),
¾ Treatment(s), procedures, equipment, medications, devices,
providing there is no lapse between the two coverages.
and supplies that are experimental or investigational.
Benefits are based on the recipient’s eligibility, not the donor's.
¾ Appliances or equipment primarily for personal comfort or
¾ Inpatient rehabilitation benefits are limited to 30 inpatient days
convenience, and therapeutic devices including eyeglasses
per calendar year. Inpatient rehabilitation benefits for head
and spinal cord injuries or stroke are increased to 60 inpatient
¾ Services and supplies available in whole or in part under any
city, county, state, or federal law.
¾ Outpatient rehabilitation benefits are limited to 30 sessions per
¾ Routine physical, mental, eye, hearing examinations or eye
calendar year. Benefits are increased to 60 sessions per
exercises (except where specifically listed).
calendar year, for head and spinal cord injuries or stroke.
¾ Surgery to alter the refractive character of the eye.
Physical exercise programs are not included.
¾ Self-help training or instructional programs (except where
¾ Skilled Nursing Facility care is limited to 14 days. If authorized
by the health plan, the benefit may be increased to 100 days.
¾ Home health care is limited to 180 visits per calendar year. ¾ Dental care is limited to the treatment of an accidental injury to
natural teeth or a fractured jaw. Diagnoses must be madewithin 6 months and treatment within 12 months after theinjury.
TDD Line for people with hearing impairments 1 (800) 382-1003
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