Portland (503)231-6399  Toll Free (888)426-9544

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

 

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

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PacificSource Application.pdf