Request for Out of Pocket Cost Estimate

Oregon's House Bill #2213 has established a framework for insurance companies to respond to consumers who would like to know in advance the ultimate cost they might be responsible for when undergoing certain medical procedures.

The Bill outlines the following medical services for consumers cost estimates:

• Office Visits
• Diagnostic Radiology and imaging
• Diagnostic pathology and laboratory procedures
• Normal child birth - vaginal delivery
• Immunizations
• Orthopedic-musculoskeletal surgery
• Digestive system endoscopy

FOUR WAYS TO OBTAIN AN OUT OF POCKET ESTIMATE:

1. CLICK HERE for an interactive connection to log in to your account
   Your User ID is your social security number and your Password is your birth date.


2. Complete this survey on-line
3. Print this survey and fax it to us
4. Print this survey and mail it to us

If you are considering one of these services and would like to know your share of expenses, simply complete the following form and one of our representatives will provide you the information within 48 hours.

Note: All contact information is required.

Once we receive your request you will be advised of the following:

1. Any deductible that may apply
2. Your cost share, or co-insurance for the procedure
3. Information about where to locate benefit information in your plan description
4. Any maximum benefit amount that may apply
5. The cost if you are using an out-of-network provider
6. Any other medically necessary services that may be a part of the common procedure for which you may have additional cost
7. A help line that you may call for additional questions
8. A toll free number to call the consumer advocacy unit of Oregon's Insurance Department

If you would rather call our office and speak to a representative to get this information, please feel free to call our office at 503.968.2360, or Toll Free at 800.777.3603