| |
$1,500, $2,000 or $3,000 Deductible |
$5,000 Deductible |
| Maximum Annual Benefit (per person) |
$2,000,000 |
| |
Annual Deductible |
Out-of-Pocket Limit(individual / family) |
Participating Provider Annual Deductible &
Out-of-Pocket (OOP) Limit
(Copayments and deductible apply to out-of-pocket
limit)
|
$1,500 per person / $3,000 per family |
$5,000/$10,000 |
| $2,000 per person / $4,000 per family |
$5,000/$10,000 |
| $3,000 per person / $6,000 per family |
$5,800/$11,600 |
| $5,000 per person / $10,000 per family |
$5,000/$10,000 |
Out-of-Pocket Limit, Nonparticipating Provider
(Minus the amount of the plan’s deductible) |
$10,000 per person |
Accident Benefit
(accident-related covered expenses) |
The first $1,000 of covered expense within 90 days of an accident is paid at 100% and is not subject to the deductible. The balance is covered
as shown below. |
| |
Participating |
Nonpar ‡ |
Participating |
Nonpar ‡ |
| Preventive Care |
| Well Baby Care |
100% + |
40% + |
100% + |
50% |
| Routine Physicals and Preventive Care Exams |
100% + † |
40% + † |
100% + † |
50% † |
| Routine Gynecological Exams |
100% + |
40% + |
100% + |
50% |
| Immunizations |
100% + |
40% + |
100% + |
50% |
| Professional Services |
| Office and Home Visits |
50% |
40% |
100% |
50% |
| Surgery
|
50% |
40% |
100% |
50% |
| Chiropractic Manipulation |
50% |
40% |
100% |
50% |
| Acupuncture
|
| Naturopathic Care
|
| Urgent Care Center Visits |
50% |
40% |
100% |
50% |
| Maternity Care |
| Practitioner Services and Hospital Stay
|
50% |
40% |
100% |
50% |
| Hospital Services |
| Inpatient Room and Board
|
50% |
40% |
100% |
50% |
| Inpatient Rehabilitative Care
|
50% |
40% |
100% |
50% |
| Skilled Nursing Facility Care
|
50% |
40% |
100% |
50% |
| Outpatient Services |
| Outpatient Hospital/Facility
|
50% |
40% |
100% |
50% |
| Diagnostic & Therapeutic Radiology and Lab
|
50% |
40% |
100% |
50% |
| Advanced Imaging
|
50% |
40% |
100% |
50% |
| Emergency Room Visits
|
50% |
40%* |
100% |
50%* |
| Other Covered Services |
| Prescription Drugs
|
50% |
Not covered |
100% |
Not covered |
| Outpatient Rehabilitative Services
|
50% |
40% |
100% |
50% |
| Allergy Injections
|
50% |
40% |
100% |
50% |
| Ambulance Service |
50% |
40% |
100% |
50% |
| Durable Medical Equipment/Prosthetics
|
50% |
40% |
100% |
50% |
| Home Health, Hospice, and Respite Care
|
50% |
40% |
100% |
50% |
| Inpatient Mental Health
|
50% |
40% |
100% |
50% |
| Transplant Services
|
50% |
Lesser of 50% of billed amount or $100,000 |
100% |
Lesser of 50% of billed amount or $100,000 |
Note:
+ = Not subject to the annual deductible.
* = Nonparticipating providers are paid at participating percentages in true medical emergencies.
† = Scheduled benefit
‡ = Payment to providers is based on the PacificSource fee allowance. While participating providers accept the fee allowance as payment in full, nonparticipating providers may not. Services
of nonparticipating providers could result in out-of-pocket expense in addition to the percentage indicated. |
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