Innova Benefit-Specific Summaries: Oregon
Effective July 1, 2011 and beyond

Each Innova plan comes with a choice of one of the four pharmacy options listed in the following table. Also, you can add one or more optional benefits, such as dental, vision and EAP riders, to accompany each plan. These optional benefits, however, cannot be sold or shown separately from the Innova plan.

 
Medical - Innova
 
Rx Option 1: $10/35%/50%
Rx Option 2: $10/$35/$75
Rx Option 3: $5/$25/$50
Rx Option 4: $7/25%/50%
80/60/60
$250 deductible; $20/$35 copay; $2,000 coinsurance
$250 deductible; $20/$35 copay; $2,000 coinsurance
$250 deductible; $20/$35 copay; $2,000 coinsurance
$250 deductible; $20/$35 copay; $2,000 coinsurance
$500 deductible; $20/$35 copay; $2,000 coinsurance
$500 deductible; $20/$35 copay; $2,000 coinsurance
$500 deductible; $20/$35 copay; $2,000 coinsurance
$500 deductible; $20/$35 copay; $2,000 coinsurance
$500 deductible; $20/$35 copay; $3,000 coinsurance
$500 deductible; $20/$35 copay; $3,000 coinsurance
$500 deductible; $20/$35 copay; $3,000 coinsurance
$500 deductible; $20/$35 copay; $3,000 coinsurance
$750 deductible; $20/$35 copay; $2,000 coinsurance
$750 deductible; $20/$35 copay; $2,000 coinsurance
$750 deductible; $20/$35 copay; $2,000 coinsurance
$750 deductible; $20/$35 copay; $2,000 coinsurance
$1,000 deductible; $20/$35 copay; $2,000 coinsurance
$1,000 deductible; $20/$35 copay; $2,000 coinsurance
$1,000 deductible; $20/$35 copay; $2,000 coinsurance
$1,000 deductible; $20/$35 copay; $2,000 coinsurance
$1,000 deductible; $20/$35 copay; $3,000 coinsurance
$1,000 deductible; $20/$35 copay; $3,000 coinsurance
$1,000 deductible; $20/$35 copay; $3,000 coinsurance
$1,000 deductible; $20/$35 copay; $3,000 coinsurance
$1,500 deductible; $20/$35 copay; $2,000 coinsurance
$1,500 deductible; $20/$35 copay; $2,000 coinsurance
$1,500 deductible; $20/$35 copay; $2,000 coinsurance
$1,500 deductible; $20/$35 copay; $2,000 coinsurance
$1,500 deductible; $20/$35 copay; $3,000 coinsurance
$1,500 deductible; $20/$35 copay; $3,000 coinsurance
$1,500 deductible; $20/$35 copay; $3,000 coinsurance
$1,500 deductible; $20/$35 copay; $3,000 coinsurance
$2,000 deductible; $20/$35 copay; $2,000 coinsurance
$2,000 deductible; $20/$35 copay; $2,000 coinsurance
$2,000 deductible; $20/$35 copay; $2,000 coinsurance
$2,000 deductible; $20/$35 copay; $2,000 coinsurance
$2,000 deductible; $20/$35 copay; $3,000 coinsurance
$2,000 deductible; $20/$35 copay; $3,000 coinsurance
$2,000 deductible; $20/$35 copay; $3,000 coinsurance
$2,000 deductible; $20/$35 copay; $3,000 coinsurance
$4,000 deductible; $20/$35 copay; $2,000 coinsurance
$4,000 deductible; $20/$35 copay; $2,000 coinsurance
$4,000 deductible; $20/$35 copay; $2,000 coinsurance
$4,000 deductible; $20/$35 copay; $2,000 coinsurance
$5,000 deductible; $20/$35 copay; $2,000 coinsurance
$5,000 deductible; $20/$35 copay; $2,000 coinsurance
$5,000 deductible; $20/$35 copay; $2,000 coinsurance
$5,000 deductible; $20/$35 copay; $2,000 coinsurance
70/50/50
$2,000 deductible; $20/$35 copay; $2,000 coinsurance
$2,000 deductible; $20/$35 copay; $2,000 coinsurance
$2,000 deductible; $20/$35 copay; $2,000 coinsurance
$2,000 deductible; $20/$35 copay; $2,000 coinsurance
$2,000 deductible; $30/$45 copay; $3,000 coinsurance
$2,000 deductible; $30/$45 copay; $3,000 coinsurance
$2,000 deductible; $30/$45 copay; $3,000 coinsurance
$2,000 deductible; $30/$45 copay; $3,000 coinsurance
$5,000 deductible; $40/$55 copay; $6,000 coinsurance
$5,000 deductible; $40/$55 copay; $6,000 coinsurance
$5,000 deductible; $40/$55 copay; $6,000 coinsurance
$5,000 deductible; $40/$55 copay; $6,000 coinsurance
 
Medical - HSA
80/60/60
$1,500/$3,000 deductible; $5,000 OOP
$2,500/$5,000 deductible; $5,000 OOP
$3,000/$5,000 deductible; $5,000 OOP
$3,500/$7,000 deductible; $5,000 OOP
100
$5,000/$10,000 deductible; $5,000 OOP
 
Dental Only Plans
Encore
$0/$500
$50/$500
$25/$750
$50/750
Expressions
$25/$,1000
$50/$1,000
$25/$1,500
$50/$1,500
$25/$2,000
$50/$2,000
Radiance
$25/$1,000
$50/$1,000
$75/$1,000
$75/$1,500
Optional Riders
8-Visit Complementary Care/Vision/EAP
24-Visit Complementary Care/Vision/EAP