PacifiCare has been marketing insurance in Oregon
since 1987.
PacifiCare Individual Plan Benefit Description
The following is a very brief outline of the plan's features. For complete
information including limitations and exclusions, please
contact
us and request a Summary of Benefits for this plan.
PacifiCare
Application
| Maximum Lifetime Benefit |
unlimited |
| Annual Deductible |
none |
The benefit amounts shown below are for use of participating providers.
Nonparticipating provider benefits are lower.
Primary
Care Physician Services
The Primary Care Physician (PCP) you select from PacifiCare's provider
directory oversees all your care, including specialty care. |
|
Plan I |
Plan II |
| Maximum Annual Out of Pocket |
$5,000
(3x Family) |
$3,000
(3x Family) |
| Routine Physicals |
$20 copay |
$15 copay |
| Routine Gynecological Exams |
$20 copay |
$15 copay |
| Well Baby and Well Child Care |
$20 copay |
$15 copay |
| Immunizations |
$20 copay |
$15 copay |
| Allergy Testing |
$20 copay |
$15 copay |
| Allergy Injections |
$20 copay |
$15 copay |
| Physician Office and Home Visits |
$20 copay |
$15 copay |
| X-rays and Lab Tests |
$20 copay |
$15 copay |
| Outpatient Surgery |
$250 copay |
$100 copay |
| Home Health Care |
$20 copay |
$15 copay |
| In-Hospital Services |
$500 copay per day |
$200 copay per day |
| Skilled Nursing Facility Care |
$250 copay per day |
$100 copay per day |
| Maternity Care, Hospital Services |
$500 copay per day |
$200 copay per day |
| Durable Medical Equipment |
20% copay |
20% copay |
| Emergency Room Services |
$100 or 50%
whichever is less |
$75 or 50%
whichever is less |
| Urgent Care |
$50 copay |
$50 copay |
| Prescription Drug |
Not
Available |
$15 generic;
$25 preferred brand;
$40 non-preferred brand.
Limited to $1,000 per person per calendar year. |
| Mental Outpatient Services |
$20 copay
Limited to 20 visits |
$20 copay
Limited to 20 visits |
| Mental Inpatient Services |
$500 copay per day |
$200 copay per day |
| Alcohol Outpatient Services |
Not Covered |
$20 copay |
| Alcohol Inpatient Services |
$500 copay per day |
$200 copay per day |
PacifiCare Individual Plan Premium Rates for the Portland
Area
(Clackamas, Columbia, Multnomah, Washington and Yamhill counties.)
Premiums are based on the age of the oldest subscriber. Premiums may be paid
monthly through automatic bank draft or quarterly by personal check. Premium
changes due to age will become effective the payment period following the
member's birthday. This applies to monthly and quarterly payments.
Rates Effective from
August 1, 2005
|
PacifiCare |
Plan I |
Plan
II |
| AGE |
FAMILY
SIZE |
|
|
| 00-01 |
Single
Male/Female |
$269.11 |
$410.37 |
| Married
Couple |
N/A |
N/A |
| Family |
N/A |
N/A |
| Single
Adult with Child(ren) |
N/A |
N/A |
| 02-17 |
Single
Male/Female |
$111.15 |
$169.50 |
| Married
Couple |
N/A |
N/A |
| Family |
N/A |
N/A |
| Single
Adult with Child(ren) |
N/A |
N/A |
| 18-29 |
Single
Male/Female |
$202.42 |
$308.67 |
| Married
Couple |
$406.00 |
$619.13 |
| Family |
$663.41 |
$1011.66 |
| Single
Adult with Child(ren) |
$478.55 |
$729.75 |
| 30-39 |
Single
Male/Female |
$226.99 |
$346.14 |
| Married
Couple |
$459.83 |
$701.20 |
| Family |
$783.93 |
$1195.43 |
| Single
Adult with Child(ren) |
$551.09 |
$840.37 |
| 40-49 |
Single
Male/Female |
$264.43 |
$403.23 |
| Married
Couple |
$535.88 |
$817.18 |
| Family |
$833.07 |
$1270.37 |
| Single
Adult with Child(ren) |
$561.62 |
$856.43 |
| 50-54 |
Single
Male/Female |
$376.75 |
$574.52 |
| Married
Couple |
$753.51 |
$1149.04 |
| Family |
$888.06 |
$1354.23 |
| Single
Adult with Child(ren) |
$568.64 |
$867.13 |
| 55-59 |
Single
Male/Female |
$456.32 |
$695.85 |
| Married
Couple |
$912.63 |
$1391.70 |
| Family |
$1048.36 |
$1598.67 |
| Single
Adult with Child(ren) |
$651.71 |
$993.82 |
| 60-64 |
Single
Male/Female |
$572.15 |
$872.48 |
| Married
Couple |
$1144.30 |
$1744.97 |
| Family |
$1278.85 |
$1950.16 |
| Single
Adult with Child(ren) |
$787.44 |
$1200.78 |
| 65+ |
Single
Male/Female |
$686.81 |
$1047.34 |
| Married
Couple |
$1372.46 |
$2092.90 |
| Family |
$1535.09 |
$2340.90 |
| Single
Adult with Child(ren) |
$944.22 |
$1439.87 |
PacifiCare Individual Plan Premium Rates for the Salem Area
(Marion and Polk counties.)
Rates Effective from
August 1, 2005
|
PacifiCare |
Plan I |
Plan
II |
| AGE |
FAMILY
SIZE |
|
|
| 00-01 |
Single
Male/Female |
$268.91 |
$410.07 |
| Married
Couple |
N/A |
N/A |
| Family |
N/A |
N/A |
| Single
Adult with Child(ren) |
N/A |
N/A |
| 02-17 |
Single
Male/Female |
$111.07 |
$169.38 |
| Married
Couple |
N/A |
N/A |
| Family |
N/A |
N/A |
| Single
Adult with Child(ren) |
N/A |
N/A |
| 18-29 |
Single
Male/Female |
$202.27 |
$308.45 |
| Married
Coupe |
$405.71 |
$618.67 |
| Family |
$662.93 |
$1010.92 |
| Single
Adult with Child(ren) |
$478.20 |
$729.22 |
| 30-39 |
Single
Male/Female |
$226.82 |
$345.89 |
| Married
Couple |
$459.49 |
$700.69 |
| Family |
$783.36 |
$1194.56 |
| Single
Adult with Child(ren) |
$550.69 |
$839.76 |
| 40-49 |
Single
Male/Female |
$264.24 |
$402.94 |
| Married
Couple |
$535.49 |
$816.58 |
| Family |
$832.46 |
$1269.44 |
| Single
Adult with Child(ren) |
$561.21 |
$855.8 |
| 50-54 |
Single
Male/Female |
$376.48 |
$574.10 |
| Married
Couple |
$752.96 |
$1148.20 |
| Family |
$887.42 |
$1353.24 |
| Single
Adult with Child(ren) |
$568.23 |
$866.50 |
| 55-59 |
Single
Male/Female |
$455.98 |
$695.34 |
| Married
Couple |
$911.97 |
$1390.68 |
| Family |
$1047.59 |
$1597.50 |
| Single
Adult with Child(ren) |
$651.24 |
$993.09 |
| 60-64 |
Single
Male/Female |
$571.73 |
$871.85 |
| Married
Couple |
$1143.47 |
$1743.70 |
| Family |
$1277.93 |
$1948.74 |
| Single
Adult with Child(ren) |
$786.86 |
$1199.91 |
| 65+ |
Single
Male/Female |
$686.31 |
$1046.58 |
| Married
Couple |
$1371.46 |
$2091.37 |
| Family |
$1533.98 |
$2339.20 |
| Single
Adult with Child(ren) |
$943.54 |
$1438.82 |
PacifiCare Individual Plan Premium Rates for the Corvallis
& Eugene Areas
(Linn, Benton and Lane counties.)
Rates Effective from
August 1, 2005
|
PacifiCare |
Plan I |
Plan
II |
| AGE |
FAMILY
SIZE |
|
|
| 00-01 |
Single
Male/Female |
$295.98 |
$451.34 |
| Married
Couple |
N/A |
N/A |
| Family |
N/A |
N/A |
| Single
Adult with Child(ren) |
N/A |
N/A |
| 02-17 |
Single
Male/Female |
$122.25 |
$186.42 |
| Married
Couple |
N/A |
N/A |
| Family |
N/A |
N/A |
| Single
Adult with Child(ren) |
N/A |
N/A |
| 18-29 |
Single
Male/Female |
$222.63 |
$339.49 |
| Married
Couple |
$446.54 |
$680.94 |
| Family |
$729.64 |
$1112.66 |
| Single
Adult with Child(ren) |
$526.32 |
$802.60 |
| 30-39 |
Single
Male/Female |
$249.65 |
$380.70 |
| Married
Couple |
$505.73 |
$771.21 |
| Family |
$862.19 |
$1314.78 |
| Single
Adult with Child(ren) |
$606.11 |
$924.27 |
| 40-49 |
Single
Male/Female |
$290.83 |
$443.49 |
| Married
Couple |
$589.38 |
$898.76 |
| Family |
$916.24 |
$1397.20 |
| Single
Adult with Child(ren) |
$617.69 |
$941.93 |
| 50-54 |
Single
Male/Female |
$414.37 |
$631.88 |
| Married
Couple |
$828.73 |
$1263.76 |
| Family |
$976.72 |
$1489.43 |
| Single
Adult with Child(ren) |
$625.41 |
$953.71 |
| 55-59 |
Single
Male/Female |
$501.87 |
$765.32 |
| Married
Couple |
$1003.74 |
$1530.65 |
| Family |
$1153.02 |
$1758.28 |
| Single
Adult with Child(ren) |
$716.78 |
$1093.04 |
| 60-64 |
Single
Male/Female |
$629.27 |
$959.59 |
| Married
Couple |
$1258.54 |
$1919.19 |
| Family |
$1406.53 |
$2144.86 |
| Single
Adult with Child(ren) |
$866.05 |
$1320.67 |
| 65+ |
Single
Male/Female |
$755.38 |
$1151.91 |
| Married
Couple |
$1509.48 |
$2301.85 |
| Family |
$1688.35 |
$2574.62 |
| Single
Adult with Child(ren) |
$1038.49 |
$1583.63 |
PacifiCare
Application
Privacy Statement- This request will be absolutely
confidential. The information will not be sold, given away or
used for any other purpose but to mail or email requested information.
Information Request Form
This is not an application for insurance. In the state of Oregon,
Individual Health Insurance plans must be approved in the underwriting stage
of the insurance application. This might take a few weeks to complete.
Please leave your name address and questions and any information that you
would like.
