| |
Elect Plus
|
|
Maximum Lifetime Benefit
|
$2,000,000
|
| |
Annual Deductible
|
Out-of-Pocket Limit
(per person) |
Annual Deductible &
Participating Provider Out-of-Pocket Limit
Total member Out-of-Pocket (OOP)
Limit is the Deductible plus the Additional OOP shown.) |
$500 per person / $1,500 per family |
$4,500 |
| $750 per person / $2,250 per family |
$4,250 |
|
$1,000 per person / $3,000 per family
|
$4,000 |
|
$2,500 per person / $7,500 per family
|
$2,500 |
|
$5,000 per person / $15,000 per family
|
$5,000 |
|
$7,500 per person / $22,500 per family
|
$7,500 |
|
Out-of-Pocket Limit, Nonparticipating Provider
(Minus the amount of the plan’s deductible)
|
$10,000 per person ($500—$5,000
deductible)
$15,000 per person ($7,500 deductible)
(Minus the amount of the plan’s deductible) |
|
Accident Benefit
|
Deductible waived and
100% benefit for first $1,000 of accident-related covered expenses within
90 days |
| Preventive Care |
Participating Providers |
Non-Participating Providers
‡ |
|
Well Baby Care
|
100% after $25 copay + |
60% after $25 copay +
|
|
Routine Physicals
|
100% after $25 copay + † |
60% after $25 copay + †
|
|
Routine Gynecological Exams
|
100% after $25 copay + |
60% after $25 copay +
|
|
Immunizations
|
80% + |
60% +
|
| Professional Services |
| Office and Home Visits |
100% after $25 copay + |
60% after $25 copay +
|
|
Urgent Care Center Visits
|
80% after $50 copay +
|
60% after $50 copay +
|
|
Surgery
|
80%
|
60%
|
|
Chiropractic Manipulation
|
100% after $25 copay + |
60% after $25 copay +
|
|
Acupuncture & Naturopathic Care
|
80%
|
60%
|
| Maternity Care |
|
Practitioner Services
|
80%
|
60%
|
|
Hospital Stay
|
80%
|
60%
|
| Hospital Services |
|
Inpatient Room and Board
|
80%
|
60%
|
|
Inpatient Rehabilitative Care
|
80%
|
60%
|
|
Skilled Nursing Facility Care
|
80%
|
60%
|
| Outpatient Services |
|
Outpatient Hospital/Facility
|
80%
|
60%
|
|
Diagnostic & Therapeutic Radiology and Lab
|
80%
|
60%
|
|
CT Scans and MRIs
|
80%
|
60%
|
|
Emergency Room Visits
|
80%
|
60%
|
| Other Covered Services |
|
Prescription Drugs
|
50% (not subject to deductible) |
Not Covered
|
|
Physical Therapy
|
80%
|
60%
|
|
Allergy Injections
|
80%
|
60%
|
|
Ambulance Service
|
80%
|
60%
|
|
Durable Medical Equipment/Prosthesis
|
80%
|
50%
|
|
Home Health, Hospice, and Respite Care
|
80%
|
60%
|
|
Inpatient Mental Health Services
|
50%
|
50%
|
|
Transplant Services
|
80%
|
Lesser of 50% of billed amount or $100,000
|
Note:
+ = Not subject to the annual deductible. Applies to out-of-pocket
limit.
† = 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.
*** The above stated out-of-pocket maximum limit amounts apply to the period
of January 1 to December 31 of each year. Only participating provider expense
applies to the participating provider out-of-pocket limit and only the nonparticipating
provider expense applies to the nonparticipating out-of-pocket limit. Once
the participating provider out-of-pocket limit has been met, this plan will
pay 100% of participating providers’ covered charges for the individual
for the rest of that calendar year. Once the nonparticipating provider out-of-pocket
limit has been met, this plan will pay 100% of nonparticipating providers’
covered charges for the individual for the rest of the calendar year. Deductibles,
prescription drug charges, benefits paid in full, and charges for services
of nonparticipating providers in excess of the allowable fee do not accumulate
toward the out-of-pocket limit amount. |
Plan Updates 
