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Elect Preferred 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 $30 copay	50% after $30 copay
Routine Gynecological Exams	100% after $30 copay	50% after $30 copay
Well Baby Care	100% after $30 copay	50% after $30 copay
Immunizations	70%	50%
Accident Benefit (Deductible waived for treatment within the first 90 days)	100%  $1,000 limit
Chiropractic Care and Acupuncture	100% after $30 copay	50% after $30 copay
Urgent Care Visits	100% after $50 copay	50% after $50 copay
Physician Office and Home Visits	100% after $30 copay	50% after $30 copay
Prescription Drugs	50%	not covered

 

MAJOR MEDICAL BENEFITS (paid after annual deductible is met)
	Participating Providers	Nonparticipating Providers
Practitioner Services	70%	50%
Surgeon and Assistant Surgeon	70%	50%
Naturopathic Care	70%	50%
Physician Hospital Visits	70%	50%
Anesthesiologist	70%	50%
Diagnostic Radiology and Lab Services	70%	50%
Radiology Services	70%	50%
Physical/Occupational Therapy	70%	50%
Allergy Injections	70%	50%
Hospital Room and Board	70%	50%
Emergency Room	70% after $100 copay	50%
Skilled Nursing Facility	70%	50%
Rehabilitative Care	70%	50%
Maternity Care, Physician Services	70%	50%
Maternity Care, Hospital Services	70%	50%
Inpatient Mental Health Services	70%	50%
Ambulance Service	70%	50%
Durable Medical Equipment/Prosthesis	70%	50%
Home Health	70%	50%
Blood and Blood Plasma	70%	50%
Transplant Services	70%	50%
Artificial Limbs and Eyes	70%	50%
Hospice and Respite Care	70%	50%

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