Health Net of Oregon Emerald 40 Plan Information
Plan Name: Emerald 40
Routine mammography: PPO Network: $40 per visit/ Out-of-Network: 50% UCR plus
Physician services, office call: PPO Network: $40 per visit/ Out-of-Network: 50% UCR plus
Physician services, urgent care center: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Well Baby Care: PPO Network: PPO Network: $40 per visit/ Out-of-Network: 50% UCR plus
Physician hospital visits: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Dianostic X-ray/EKG/Ultrasound: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Diagnostic laboratory tests: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
CT/MRI/PET/SPECT/EEG/Holter monitor/Stress test: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Allergy and therapeutic injections: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Maternity delivery care: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Outpatient rehabilitation therapy: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Outpatient or ambulatory care center: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Inpatient services: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Inpatient rehabilitation therapy: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Outpatient emergency room services: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Inpatient admission from emergency room: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Emergency ambulance transport: 30% (UCR plus applies to Out-of-Network Providers)
Outpatient Mental health: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Inpatient Mental Health: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Durable medical equipment/external prosthetic devices: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Medical supplies: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Diabetes management: PPO Network: $40 per visit/ Out-of-Network: 50% UCR plus
Blood, blood plasma, blood derivatives: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
TMJ services: PPO Network: 50% contract rate/ Out-of-Network: 50% UCR plus
Home infusion therapy: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Skilled nursing facility care: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Hospice services: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Home health visits: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Outpatient neurodevelopmental therapy: PPO Network: 30% contract rate/ Out-of-Network: 50% UCR plus
Health education: Any charges over maximum reimbursement of $50/qualifying class.
Annual Copayment maximum per person: $6,000 $12,000
Annual Copayment maximum per family: $18,000 $36,000
Lifetime maximum for authorized organ transplant services: $250,000 Not covered Out-of-Network
Lifetime Maximum: $2,000,000 PPO Network and Out-of-Network combined
Prescription Drugs: Yes
Alternative Care: No
Other Health Net of Oregon health insurance plans:
