Physical Health Benefits

Doctor Visits

Primary Care Provider (PCP)

  • No referral required
  • No limit with assigned PCP

Specialist

  • Referral required from your PCP for most physical health services • Number of visits based health plan’s approval
  • Number of visits based health plan’s approval

Preventative Services

Well-child visits (babies, kids & teens)

  • Referral: No referral required
  • Limits: As recommended

Routine physicals

  • Referral: No referral required
  • Limits: As recommended

Well-women visits

  • Referral: No referral required
  • Limits: As recommended

Mammograms (breast x-rays)

  • Referral: Yes, referral required
  • Limits: As recommended

Family Planning

  • Referral: No referral required
  • Limits: No limit

Prostate exams

  • Referral: No referral required
  • Limits: No limit

Sexually transmitted disease (STD) screening

  • Referral: No referral required
  • Limits: No limit

Testing & counseling for HIV and AIDS

  • Referral: No referral required
  • Limits: No limit

Prescription Drugs

Many drugs are available with a prescription.

A full list of drugs can be found on your health plan’s “formulary”.

To find your health plan’s formulary, visit: HealthShareOregon.org/formularies

  • Referral: You may need approval, also called “prior authorization”, in addition to your prescription.
    Your doctor will let you know if you need authorization.
  • Limits: Limits vary by drug. Contact your physical health plan for more info

Mental Health Drugs

Mental Health Drugs are not covered by your Health Share physical health plan or behavioral health plan. They are covered directly by the OHP. Your pharmacist will know where to send the bill.

  • Referral: Contact OHP
  • Limits: Contact OHP

Laboratory and X-Ray

Blood draw

  • Referral: Yes, referral required
  • Limits: No limit

X-Rays

  • Referral: Yes, referral required
  • Limits: No limit

CT Scans

  • Referral: Yes, referral required
  • Limits: No limit

MRI

  • Referral: Yes, referral required
  • Limits: No limit

Immunizations/Shots

Vaccines

  • Referral: Not required for recommended vaccines
  • Limits: Contact your physical health plan

Pregnancy Care

Prenatal visits with your provider

  • Referral: No referral required
  • Limits: No limit

Postpartum care (care for the mother after the baby is born)

  • Referral: No referral required
  • Limits: No limit

Routine vision services (pregnant women qualify for vision care)

  • Referral: Contact your physical health plan
  • Limits: Contact your physical health plan

Assistance with breast feeding, including breast pumps

  • Referral: No referral required
  • Limits: Contact your physical health plan

Labor and delivery

  • Referral: No referral required
  • Limits: Contact your physical health plan

Hospital Stays

Emergencies

  • Referral: No referral required
  • Limits: No limit

Scheduled surgery

  • Referral: Yes, authorization required
  • Limits: Contact your physical health plan

PT/OT/ST

Physical therapy (PT)

  • Referral: Yes, authorization required
  • Limits: Up to 30 combined visits (PT, OT, ST) per calendar year with covered medical condition.

Occupational therapy (OT)

  • Referral: Yes, authorization required
  • Limits: Up to 30 combined visits (PT, OT, ST) per calendar year with covered medical condition.

Speech therapy (ST)

  • Referral: Yes, authorization required
  • Limits: Up to 30 combined visits (PT, OT, ST) per calendar year with covered medical condition.

Vision

Routine eye exams

  • Referral: Contact your physical health plan
  • Limits: Available to pregnant women and people aged 20 or younger

Eye glasses

  • Referral: Contact your physical health plan
  • Limits: Available to pregnant women and people aged 20 or younger

Medical eye exams

  • Referral: Yes, authorization required
  • Limits: Contact your physical health plan.

Other Specialty Services

Medical equipment and supplies

  • Referral: Yes, authorization required
  • Limits: Approval based on OHP guidelines. Contact your physical health plan.

Hearing aids and exams

  • Referral: Yes, authorization required
  • Limits: Approval based on OHP guidelines. Contact your physical health plan.

Home health

  • Referral: Yes, authorization required
  • Limits: Approval based on OHP guidelines. Contact your physical health plan.

Skilled nursing facilities

  • Referral: Yes, authorization required
  • Limits: Approval based on OHP guidelines. Contact your physical health plan.

Hospice

  • Referral: Yes, authorization required
  • Limits: Approval based on OHP guidelines. Contact your physical health plan.

Chiropractor

  • Referral: Yes, authorization required
  • Limits: Approval based on OHP guidelines. Contact your physical health plan.

Acupuncture

  • Referral: Yes, authorization required
  • Limits: Approval based on OHP guidelines. Contact your physical health plan.