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PacificSource Health Insurance

PacificSource Health Plans of Oregon

PacificSource Health Plans - Electronic Application

Index | Plan Limitations | Eligibility | Locate Providers | Download Application
Plan Benefits:
Elect Premiere | Elect Preferred | Elect HSA | Elect Value Option
Plan Rates:
Elect Premiere | Elect Preferred | Elect HSA | Elect Value Option

 
Elect Value Option

Maximum Annual Benefit (per person)

$2,000,000

 

Annual Deductible

Out-of-Pocket Limit (per person)

Participating Provider Annual Deductible & Out-of-Pocket (OOP) Limit
(Copayments and deductible apply to out-of- pocket limit, except for prescription drug expenses)

$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)
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.
Preventive Care Participating Providers Non-Participating Providers

Well Baby Care

100% +

50%

Routine Physicals and Preventive Care Exams

100% + †

50%

Routine Gynecological Exams

100% +

50%

Immunizations

100% +

50%

Professional Services
Office and Home Visits 60%

50%

Surgery

60%

50%

Chiropractic Manipulation

Not covered

Not covered

Acupuncture

Naturopathic Care Not covered

Not covered

Urgent Care Visits

60% 50%
Maternity Care

Practitioner Services and Hospital Stay

60%

50%

Hospital Services

Inpatient Room and Board

60%

50%

Inpatient Rehabilitative Care

60%

50%

Inpatient Rehabilitative Care

60%

50%

Outpatient Services

Outpatient Hospital/Facility

60%

50%

Diagnostic & Therapeutic Radiology and Lab

60%

50%

Advanced Imaging

60%

50%

Emergency Room Visits

60%

50%*

Other Covered Services

Prescription Drugs

50%

Not Covered

Outpatient Rehabilitative Care

60%

50%

Allergy Injections

60%

50%

Ambulance Service

60%

50%

Durable Medical Equipment/Prosthetics

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.
* = 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.

*** 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.


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