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Elect Premiere Benefit Description

 

Maximum Lifetime Benefit	$2,000,000
Annual Deductible per person/family	Out of pocket limit including deductible per person
$500/$1,500	$5,000
$750/$2,250	$5,000
$1,000/$3,000	$5,000
$2, 500/$7,500	$5,000
$5,000/$15,000	$10,000
$7,500/$22,500	$15,000
$10,000/$30,000	$20,000
Out-of-Pocket Limit for nonparticipating providers (minus the amount of the plan's deductible)	$10,000 per person ($500-$5,000 deductible) $15,000 per person ($7,500 deductible) $20,000 per person ($10,000 deductible)

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.

 

BASE BENEFITS (not subject to deductible)
	Participating Providers	Nonparticipating Providers
Routine Physicals	100% after $25 copay	60% after $25 copay
Routine Gynecological Exams	100% after $25 copay	60% after $25 copay
Well Baby Care	100% after $25 copay	60% after $25 copay
Immunizations	100% after $25 copay	60% after $25 copay
Accident Benefit (Deductible waived for treatment within the first 90 days)	100%  $5,000 limit
Chiropractic Care and Acupuncture	100% after $25 copay	60% after $25 copay
Naturopathic Care	100% after $25 copay	60% after $25 copay
Routine Vision Exam 1 exam every 2 calendar years	100% after $25 copay	60% after $25 copay
Vision Hardware	$200 for frames, lenses or contacts (per 2 calendar years)
Urgent Care Visits	100% after $25 copay	60% after $25 copay
Physician Office and Home Visits	100% after $25 copay	60% after $25 copay
Prescription Drugs	Generic $15 copay Brand drugs 50%	not covered

 

MAJOR MEDICAL BENEFITS (paid after annual deductible is met)
	Participating Providers	Nonparticipating Providers
Practitioner Services	80%	60%
Surgeon and Assistant Surgeon	80%	60%
Physician Hospital Visits	80%	60%
Anesthesiologist	80%	60%
Diagnostic Radiology and Lab Services	80%	60%
Radiology Services	80%	60%
Physical/Occupational Therapy	80%	60%
Allergy Injections	80%	60%
Hospital Room and Board	80%	60%
Emergency Room	80% after $100 copay	60% after $100 copay
Skilled Nursing Facility	80%	60%
Rehabilitative Care	80%	60%
Maternity Care, Physician Services*	80%	60%
Maternity Care, Hospital Services*	80%	60%
Inpatient Mental Health Services	80%	60%
Ambulance Service	80%	60%
Durable Medical Equipment/Prosthesis	80%	50%
Home Health	80%	60%
Blood and Blood Plasma	80%	60%
Transplant Services	80%	50%
Artificial Limbs and Eyes	80%	60%
Hospice and Respite Care	80%	60%

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.

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PacificSource Application.pdf