Elect Plan Exclusions from PacificSource Health Plans for Oregon

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Oregon Medical Insurance > PacificSource Health Plans > Elect Plan Exclusions Specific Benefit Limitations Ambulance service - ground 300 miles/year; air $6,000/year Cardiac rehabilitation (phase II)—$1,000/lifetime Chiropractic manipulation (covered under Elect Plus only)—12 visits/year Dietary/nutritional counseling for anorexia or bulimia—5 visits/lifetime Durable medical equipment—$7,500/lifetime Flu vaccine (covered under Elect Plus and FlexPerks only)—$20/year Hospice or respite care—$10,000/lifetime Mental health treatment (inpatient)—$1,000/lifetime Naturopathic and acupuncture care (covered under ElectPlus only)—$1,000/year combined Physical therapy—20 visits/year Prescription drug expense—does not accumulate toward out-of-pocket limit on the Elect Plus and Elect Value Pulmonary rehabilitation—$1,000/lifetime Routine physical exams—(covered under Elect Plus and FlexPerks only)—scheduled. Speech therapy—$1,000/year Transplants—$250,000/lifetime Transplants, travel/housing for recipient—$5,000/transplant Transplants, nonparticipating providers—$100,000 Well baby exams (covered under Elect Plus and FlexPerks only)—9 exams in the first 24 months of life, including a standard in-hospital exam at birth and related laboratory tests.
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