Senate Bill 91 (2011) Standard Plan - EHB and Cost Share Matrix - Updated for 2016 ***NOT INTENDED AS A STATEMENT OF COVERAGE***

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1 Deductible Medical: $1,250; Medical: $2,500; Integrated Medical/Rx: Rx: $0 Rx: $0 $5,000 Maximum OOP Combined Medical Combined Medical Combined Medical and and Drug: $6,350 and Drug: $6,350 Drug: $6,350 Family Multiplier 2x Individual 2x Individual 2x Individual Primary Care Office Visit to Treat an Injury or Illness $20 $35 $60 After Deductible Specialist Office Visit $40 $70 $100 After Deductible Primary Care Visit to Treat an Injury or Illness Specialist Visit Other Practitioner Office Visit (Nurse, Physician Assistant) $20 $35 $60 After Deductible Other Practitioner Office Visit (Nurse, Physician Assistant) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Hospice Respite care - max of 5 consecutive days; lifetime max of 30 days Outpatient Surgery Physician/Surgical Hospice Non-Emergency Care When Traveling Outside the U.S. Routine Dental (Adult) Infertility Treatment Long-Term/Custodial Nursing Oregon Insurance Division Page 1 of 8 Revised 6/22/2015

2 Private-Duty Nursing Routine Eye Exam (Adult) Urgent Care Centers or Facilities $60 $90 $120 After Deductible Urgent Care Centers or Facilities Home Health Care Emergency Room Home Health Care Emergency Room Emergency Transportation/ Ambulance Emergency Transportation/ Ambulance Inpatient Hospital (e.g., Hospital Stay) Inpatient Hospital (e.g., Hospital Stay) Inpatient Physician and Surgical Cosmetic Surgery Skilled Nursing Facility Prenatal and Postnatal Care 60 days per year Inpatient Physician and Surgical Bariatric Surgery Cosmetic Surgery Skilled Nursing Facility Prenatal and Postnatal Care Delivery and All Inpatient for Maternity Care Delivery and All Inpatient for Maternity Care Varies based on Varies based on Varies based on *Mental/Behavioral Health Outpatient type/place of service. Please see the applicable service type/place of service. Please see the applicable service type/place of service. Please see the applicable service Mental/Behavioral Health Outpatient Oregon Insurance Division Page 2 of 8 Revised 6/22/2015

3 *Mental/Behavioral Health Inpatient Varies based on Varies based on Varies based on type/place of service. type/place of service. type/place of service. Substance Abuse Disorder Please see the Please see the Please see the Outpatient applicable service applicable service applicable service Substance Abuse Disorder Inpatient Generic Drugs $10 $15 $20 After Deductible Preferred Brand Drugs $30 $50 $80 After Deductible Non-Preferred Brand Drugs 50% 50% 50% After Deductible Mental/Behavioral Health Inpatient Substance Abuse Disorder Outpatient Substance Abuse Disorder Inpatient Generic Drugs Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs 50% 50% 50% After Deductible *Outpatient Rehabilitation *Inpatient Habilitation $20 (Applies to PT, OT, $60 After Deductible $35 (Applies to PT, OT, (Applies to PT, OT, ST provided in an office 30 (to 60) visits per year 30 days per year.carriers must comply with federal Provider Non-discrimination provisions found in PHSA Section 2706(a). Durable Medical Equipment Specialty Drugs Outpatient Rehabilitation Habilitation Chiropractic Care Durable Medical Equipment Oregon Insurance Division Page 3 of 8 Revised 6/22/2015

4 Hearing Aids Hearing Aids Imaging (CT/PET Scans, MRIs) Imaging (CT/PET Scans, MRIs) ACA Preventive $0 $0 $0 Preventive Care/ Screening/Immunization Routine Foot Care Exams at $0 for these codes: 92002/92004, 92012/92014, S0620/S0621; for other codes cost shares may apply. Routine Foot Care Acupuncture Weight Loss Programs Routine Eye Exam for Children Pediatric Vision Contact lenses - Actuarial equivalent of $150 per year. Frames - Actuarial equivalent of $150 per year. Lenses at $0 for codes V , V , V2121, V2221, V2321; for other codes cost shares may apply. Eye Glasses for Children Dental Check-Up for Children *Outpatient Rehabilitation $20 (Applies to PT, OT, $35 (Applies to PT, OT, $60 After Deductible (Applies to PT, OT, ST provided in an office 30 (to 60) visits per year Rehabilitative Speech Therapy Rehabilitative Occupational and Rehabilitative Physical Therapy Oregon Insurance Division Page 4 of 8 Revised 6/22/2015

5 ACA Preventive $0 $0 $0 Well Baby Visits and Care Diagnostic Test (X-Ray and Lab Work) Laboratory Outpatient and Professional X-rays and Diagnostic Imaging Basic Dental Care - Child Orthodontia - Child Major Dental Care - Child Basic Dental Care - Adult Orthodontia - Adult Major Dental Care - Adult Outpatient Abortion for Which Public Funding is Prohibited Organ Transplants Transplant Emergency Room Accidental Dental Outpatient Dialysis Allergy Injections Allergy Testing Oregon Insurance Division Page 5 of 8 Revised 6/22/2015

6 Chemotherapy Outpatient Radiation Diabetes Education Oregon Mandates (ORS 743 and 743A) Prosthetic Devices Outpatient Outpatient Infusion Therapy Treatment for Temporomandibular Joint Disorders Nutritional Counseling Cosmetic Surgery Reconstructive Surgery Oregon Mandates (ORS 743 and 743A) Clinical Trials Inherited Metabolic Disorder - PKU Specialty Drugs 50% 50% 50% After Deductible Specialty Drugs 50% 50% 50% After Deductible Off Label Prescription Drugs Prescription Drugs Other Oregon Insurance Division Page 6 of 8 Revised 6/22/2015

7 Breast Reconstruction *Outpatient Rehabilitation Biofeedback $20 $35 $60 After Deductible 10 treatments per lifetime 36 sessions of cardiac rehabilitation exercise 30 days per year $60 After Deductible $20 (Applies to PT, OT, $35 (Applies to PT, OT, (Applies to PT, OT, ST provided in an office 30 (to 60) visits per year Cardiac Rehabilitation $20 $35 $60 After Deductible Hospitalization for Dental Proceedures *Inpatient Rehabilitation *Outpatient Habilitation $20 (Applies to PT, OT, $60 After Deductible $35 (Applies to PT, OT, (Applies to PT, OT, ST provided in an office 30 (to 60) visits per year Mastectomy-Related Coverage Brain Injury Covered with same cost shares as Non-Specialist Visit as Rehabilitation and visit of Inpatient and Outpatient Hospital and visit of Inpatient Habilitation and visit as Outpatient Rehabilitation Oregon Insurance Division Page 7 of 8 Revised 6/22/2015

8 Sleep Studies Vasectomy as Outpatient as under Outpatient Surgery *Mental Health covered under Habilitation and Rehabilitation must comply with state and federal rules on Mental Health Parity. Carriers should review state and federal laws regarding mental health parity for benefits and limitations, including visit limitations, in relation to requirements outlined in If carriers apply benefit limitations to mental health services the carrier will be required to prove compliance with state and federal law. Chiropractic Care: Benefits otherwise covered by the plan must be covered if provided by a doctor of chiropractic acting within the scope of their license. (PHSA 2706(a)) Most cost shares apply to in-network benefits only. Out-of-network benefits, if available, are defined by the insurer. Emergency must be covered at the same cost share for both in and out-of-network, however, different maximum out-of-pocket costs and balance billing may apply. Provider contracting varies between insurers. Oregon Insurance Division Page 8 of 8 Revised 6/22/2015

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