Innova Benefit-Specific Summaries: Oregon
Effective January 1, 2012

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
$500 Ded; $20/$35 copay; $2,000 OOP
$500 Ded; $20/$35 copay; $2,000 OOP
$500 Ded; $20/$35 copay; $2,000 OOP
$500 Ded; $20/$35 copay; $2,000 OOP
$750 Ded; $20/$35 copay; $2,000 OOP
$750 Ded; $20/$35 copay; $2,000 OOP
$750 Ded; $20/$35 copay; $2,000 OOP
$750 Ded; $20/$35 copay; $2,000 OOP
$750 Ded; $20/$35 copay; $3,000 OOP
$750 Ded; $20/$35 copay; $3,000 OOP
$750 Ded; $20/$35 copay; $3,000 OOP
$750 Ded; $20/$35 copay; $3,000 OOP
$1,000 Ded; $20/$35 copay; $2,000 OOP
$1,000 Ded; $20/$35 copay; $2,000 OOP
$1,000 Ded; $20/$35 copay; $2,000 OOP
$1,000 Ded; $20/$35 copay; $2,000 OOP
$1,000 Ded; $20/$35 copay; $3,000 OOP
$1,000 Ded; $20/$35 copay; $3,000 OOP
$1,000 Ded; $20/$35 copay; $3,000 OOP
$1,000 Ded; $20/$35 copay; $3,000 OOP
$1,500 Ded; $20/$35 copay; $2,000 OOP
$1,500 Ded; $20/$35 copay; $2,000 OOP
$1,500 Ded; $20/$35 copay; $2,000 OOP
$1,500 Ded; $20/$35 copay; $2,000 OOP
$1,500 Ded; $20/$35 copay; $3,000 OOP
$1,500 Ded; $20/$35 copay; $3,000 OOP
$1,500 Ded; $20/$35 copay; $3,000 OOP
$1,500 Ded; $20/$35 copay; $3,000 OOP
$2,000 Ded; $20/$35 copay; $3,000 OOP
$2,000 Ded; $20/$35 copay; $3,000 OOP
$2,000 Ded; $20/$35 copay; $3,000 OOP
$2,000 Ded; $20/$35 copay; $3,000 OOP
$2,000 Ded; $30/$45 copay; $3,000 OOP
$2,000 Ded; $30/$45 copay; $3,000 OOP
$2,000 Ded; $30/$45 copay; $3,000 OOP
$2,000 Ded; $30/$45 copay; $3,000 OOP
$4,000 Ded; $20/$35 copay; $2,000 OOP
$4,000 Ded; $20/$35 copay; $2,000 OOP
$4,000 Ded; $20/$35 copay; $2,000 OOP
$4,000 Ded; $20/$35 copay; $2,000 OOP
$5,000 Ded; $20/$35 copay; $2,000 OOP
$5,000 Ded; $20/$35 copay; $2,000 OOP
$5,000 Ded; $20/$35 copay; $2,000 OOP
$5,000 Ded; $20/$35 copay; $2,000 OOP
90/70/70
$5,000 Ded; $20/$35 copay; $2,000 OOP
$5,000 Ded; $20/$35 copay; $2,000 OOP
$5,000 Ded; $20/$35 copay; $2,000 OOP
$5,000 Ded; $20/$35 copay; $2,000 OOP
70/50/50
$1,000 Ded; $20/$35 copay; $2,000 OOP
$1,000 Ded; $20/$35 copay; $2,000 OOP
$1,000 Ded; $20/$35 copay; $2,000 OOP
$1,000 Ded; $20/$35 copay; $2,000 OOP
$1,500 Ded; $20/$35 copay; $2,000 OOP
$1,500 Ded; $20/$35 copay; $2,000 OOP
$1,500 Ded; $20/$35 copay; $2,000 OOP
$1,500 Ded; $20/$35 copay; $2,000 OOP
$1,500 Ded; $20/$35 copay; $3,000 OOP
$1,500 Ded; $20/$35 copay; $3,000 OOP
$1,500 Ded; $20/$35 copay; $3,000 OOP
$1,500 Ded; $20/$35 copay; $3,000 OOP
$2,000 Ded; $20/$35 copay; $2,000 OOP
$2,000 Ded; $20/$35 copay; $2,000 OOP
$2,000 Ded; $20/$35 copay; $2,000 OOP
$2,000 Ded; $20/$35 copay; $2,000 OOP
$7,500 Ded; $40/$55 copay; $4,000 OOP
$7,500 Ded; $40/$55 copay; $4,000 OOP
$7,500 Ded; $40/$55 copay; $4,000 OOP
$7,500 Ded; $40/$55 copay; $4,000 OOP
$7,500 Ded; $40/$55 copay; $6,000 OOP
$7,500 Ded; $40/$55 copay; $6,000 OOP
$7,500 Ded; $40/$55 copay; $6,000 OOP
$7,500 Ded; $40/$55 copay; $6,000 OOP
 
Medical - HSA
80/60/60
$1,500/$3,000 Ded; $5,000 OOP
$2,500/$5,000 Ded; $5,000 OOP
$3,500/$7,000 Ded; $5,000 OOP
$3,000/$5,000 Ded; $5,000 OOP
100
$5,000/$10,000 Ded; $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
Optional riders: Complementary Care / Vision / EAP 8 visits per year
Optional riders: Complementary Care / Vision / EAP 24 visits per year