| |
Elect Value Option |
|
Maximum Lifetime Benefit |
$2,000,000 |
| |
Annual Deductible |
Out-of-Pocket Limit
(per person) |
|
Annual Deductible & Participating Provider Out-of-Pocket Limit
|
$2,500 per person / $7,500 per family |
$7,500 |
|
$5,000 per person / $15,000 per family |
$10,000 |
|
$7,500 per person / $22,500 per family |
$12,500 |
|
$10,000 per person / $30,000 per family |
$15,000 |
|
Out-of-Pocket Limit, Nonparticipating Provider
(Minus the amount of the plan’s deductible) |
$10,000 per person ($2,500 & $5,000
deductible);
$20,000 per person ($7,500 & $10,000 deductible)
(Minus the amount of the plan’s deductible) |
| Accident Benefit |
Not applicable |
| Preventive Care |
Participating Providers |
Non-Participating Providers
‡ |
|
Well Baby Care |
Not covered |
50% |
|
Routine Physicals and Preventive Care Exams |
Not covered |
Not covered |
|
Routine Gynecological Exams |
100% after $35 copay + |
50% after $35 copay + |
|
Immunizations |
Not covered |
Not covered |
| Professional Services |
| Office and Home Visits |
60% |
50% |
|
Surgery |
60% |
50% |
|
Chiropractic Manipulation |
Not covered |
Not covered |
Acupuncture |
Not covered |
Not covered |
|
Naturopathic Care |
Not covered |
Not covered |
| Maternity Care |
|
Practitioner Services |
60% |
50% |
|
Hospital Stay |
60% |
50% |
| Hospital Services |
|
Inpatient Room and Board |
60% |
50% |
|
Inpatient Rehabilitative Care |
60% |
50% |
|
Skilled Nursing Facility Care |
60% |
50% |
| Outpatient Services |
|
Outpatient Hospital/Facility |
60% |
50% |
|
Diagnostic & Therapeutic Radiology and Lab |
60% |
50% |
|
CT/PET Scans, Cath Labs, and MRIs |
60% |
50% |
|
Emergency Room Visits |
60% |
50% |
Urgent Care Center Visits |
60% |
50% |
| Other Covered Services |
|
Prescription Drugs |
50% |
Not Covered |
|
Physical Therapy |
60% |
50% |
|
Allergy Injections |
60% |
50% |
|
Ambulance Service |
60% |
50% |
|
Durable Medical Equipment/Prosthesis |
60% |
50% |
|
Home Health, Hospice, and Respite Care |
60% |
50% |
|
Inpatient Mental Health Services |
60% |
50% |
|
Transplant Services |
60% |
Lesser of 50% of billed amount or $100,000 |
Note:
+ = Not subject to the annual deductible. Applies to out-of-pocket
limit.
‡ = 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. |
Plan Updates 
