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PacificSource was formed in 1933 as an organization of member physicians. Now
that we serve all of Oregon, we put our decades of experience to work providing
our customers with affordable coverage and the best possible service.
PacificSource
Application.pdf
Preferred
Provider List of Doctors and facilities
Elect Value Benefit Description
The following is a very brief outline of the plan's features. For complete
information including limitations and exclusions, please Independent
Health Insurance Agents and request a Summary of Benefits.
| Maximum Lifetime
Benefit |
$2,000,000 |
| |
|
| Annual Deductible
per person/family
|
Out of pocket limit
including deductible per person |
| $2,500/$7500
|
$7,500 |
| $5,000/$15,000
|
$10,000 |
| $7,500/$22,500 |
$12,500 |
| $10, 000/$30,000 |
$15,000 |
Payment to providers is based on the PacificSource fee allowances.
While participating providers accept the fee allowance as payment in full,
nonparticipating providers may not, which could result in out-of-pocket expenses
in addition to the percentage indicated.
MEDICAL BENEFITS
(not subject to the annual deductible) |
| |
Participating Providers |
Nonparticipating Providers |
| Routine Gynecological Exams |
$35 copay |
50% after $35 copay |
Payment to providers is based on the PacificSource fee allowances.
While participating providers accept the fee allowance as payment in full,
nonparticipating providers may not, which could result in out-of-pocket expenses
in addition to the percentage indicated.
MAJOR
MEDICAL BENEFITS
(paid after annual deductible is met) |
| |
Participating Providers |
Nonparticipating Providers |
| Office and home visits |
60% |
50% |
| Urgent Care Visits |
60% |
50% |
| Surgeon and Assistant Surgeon |
60% |
50% |
| Physician Hospital Visits |
60% |
50% |
| Hospital Services |
60% |
50% |
| Anesthesiologist |
60% |
50% |
| Diagnostic Radiology and Lab Services |
60% |
50% |
| Radiology Services |
60% |
50% |
| Physical Therapy |
60% |
50% |
| Emergency Room Visits |
60% |
50% |
| Allergy Injections |
60% |
50% |
| Hospital Room and Board |
60% |
50% |
| Skilled Nursing Facility |
60% |
50% |
| Rehabilitative Care |
60% |
50% |
| Maternity Care, Physician Services |
60% |
50% |
| Maternity Care, Hospital Services |
60% |
50% |
| Inpatient Mental Health Services |
60% |
50% |
| Ambulance Service |
60% |
50% |
| Durable Medical Equipment/Prosthesis |
60% |
50% |
| Home Health |
60% |
50% |
| Blood and Blood Plasma |
60% |
50% |
| Transplant Services |
60% |
50% |
| Artificial Limbs and Eyes |
60% |
50% |
| Hospice and Respite Care |
60% |
50% |
| Prescription Drugs |
50% |
No benefit |
| Well Baby Care |
not covered |
| Routine Physicals |
not covered |
| Immunizations |
Not covered |
Elect Value Premium Rates
Monthly premium for Elect Value is step-rated based on the
age of the oldest family member on the policy. Premium rates for this plan
effective January 1, 2008 are as follows.
|
|
Individual
|
Individual
|
Family
|
Individual
|
|
|
|
|
&Spouse
|
&Child(ren)
|
|
Age
|
Deductible
$2,500
|
|
0-17
|
51
|
|
|
|
|
18-24
|
65
|
130
|
188
|
117
|
|
25-29
|
77
|
154
|
231
|
139
|
|
30-34
|
87
|
174
|
261
|
157
|
|
35-39
|
100
|
200
|
300
|
180
|
|
40-44
|
126
|
252
|
353
|
227
|
|
45-49
|
142
|
283
|
396
|
255
|
|
50-54
|
190
|
380
|
475
|
342
|
|
55-59
|
233
|
466
|
536
|
419
|
|
60-64
|
270
|
540
|
594
|
468
|
|
65+
|
270
|
540
|
594
|
486
|
|
|
Individual
|
Individual
|
Family
|
Individual
|
|
|
|
|
&Spouse
|
&Child(ren)
|
|
Age
|
Deductible
$5,000
|
|
0-17
|
32
|
|
|
|
|
18-24
|
41
|
81
|
118
|
73
|
|
25-29
|
48
|
97
|
145
|
87
|
|
30-34
|
54
|
109
|
163
|
98
|
|
35-39
|
63
|
125
|
188
|
113
|
|
40-44
|
79
|
158
|
221
|
142
|
|
45-49
|
89
|
177
|
248
|
160
|
|
50-54
|
119
|
238
|
298
|
214
|
|
55-59
|
146
|
292
|
336
|
263
|
|
60-64
|
169
|
338
|
372
|
305
|
|
65+
|
169
|
338
|
372
|
305
|
|
|
Individual
|
Individual
|
Family
|
Individual
|
|
|
|
|
&Spouse
|
&Child(ren)
|
|
Age
|
Deductible
$7,500
|
|
0-17
|
22
|
|
|
|
|
18-24
|
28
|
55
|
80
|
50
|
|
25-29
|
33
|
66
|
98
|
59
|
|
30-34
|
37
|
74
|
111
|
67
|
|
35-39
|
42
|
85
|
127
|
76
|
|
40-44
|
54
|
107
|
150
|
96
|
|
45-49
|
60
|
120
|
169
|
108
|
|
50-54
|
81
|
162
|
202
|
145
|
|
55-59
|
99
|
198
|
228
|
178
|
|
60-64
|
115
|
230
|
253
|
207
|
|
65+
|
115
|
230
|
253
|
207
|
|
|
Individual
|
Individual
|
Family
|
Individual
|
|
|
|
|
&Spouse
|
&Child(ren)
|
|
Age
|
Deductible
$10,000
|
|
0-17
|
17
|
|
|
|
|
18-24
|
21
|
42
|
62
|
38
|
|
25-29
|
25
|
50
|
76
|
45
|
|
30-34
|
28
|
57
|
85
|
51
|
|
35-39
|
33
|
65
|
98
|
59
|
|
40-44
|
41
|
82
|
115
|
74
|
|
45-49
|
46
|
92
|
129
|
83
|
|
50-54
|
62
|
124
|
155
|
112
|
|
55-59
|
76
|
152
|
175
|
137
|
|
60-64
|
88
|
176
|
194
|
159
|
|
65+
|
88
|
176
|
194
|
159
|
|
|
PacificSource
Application.pdf
Preferred
Provider List of Doctors and facilities
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.
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Send
mail to frs@xprt.net
with questions or comments about this web site.
Copyright © 1999 INDEPENDENT HEALTH INSURANCE AGENTS
PacificSource
Application.pdf
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