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Index | Exclusions
& Limitations | Locate
Providers | Application
Plan Benefits:
Elect Premiere | Elect Preferred
| Elect FlexPerks | Elect Value
Plan Rates:
Elect Premiere | Elect Preferred | Elect FlexPerks | Elect Value
LifeWise Health Plans of Oregon
Regence BC BS of OR
ODS Health Plans
PacificSource
Providence Health Plans
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Oregon Medical Insurance Pool
Medicare Supplement Plans
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Other Insurance
Oregon Medical Insurance > PacificSource Health Plans > Elect Preferred Benefits
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Elect Preferred |
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Maximum Lifetime Benefit |
$2,000,000 |
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|
Annual Deductible |
Out-of-Pocket Limit (per person) | |
| Participating Provider Annual Deductible &
Out-of-Pocket (OOP) Limit (Copayments and deductible apply to out-of- pocket limit, except for prescription drug expenses) |
$500 per person / $1,500 per family | $5,000 |
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$1,000 per person / $3,000 per family |
$5,000 | |
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$2,500 per person / $7,500 per family |
$5,000 | |
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$5,000 per person / $15,000 per family |
$10,000 | |
$7,500 per person / $22,500 per family |
$15,000 | |
$10,000 per person / $30,000 per family |
$20,000 | |
|
Out-of-Pocket Limit, Nonparticipating Provider |
$10,000 per person ($500—$5,000
deductible) $15,000 per person ($7,500 deductible) $20,000 per person ($10,000 deductible) |
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Accident Benefit (accident-related covered expenses) |
The first $1,000 within 90 days is covered at 100%, deductible waived. | |
| Preventive Care | Participating Providers | Non-Participating Providers ‡ |
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Well Baby Care |
100% after $30 copay + |
50% after $30 copay + |
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Routine Physicals and Preventive Care Exams |
100% after $30 copay + † |
50% after $30 copay + † |
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Routine Gynecological Exams |
100% after $30 copay + |
50% after $30 copay + |
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Immunizations |
70% + |
50% + |
| Professional Services | ||
| Office and Home Visits | 100% after $30 copay + |
50% after $30 copay + |
|
Surgery |
70% |
50% |
| Chiropractic Manipulation | 100% after $30 copay + |
50% after $30 copay + |
Acupuncture |
70% |
50% |
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Naturopathic Care |
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| Urgent Care Center Visits | 100% after $50 copay + | 50% after $50 copay + |
| Maternity Care | ||
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Practitioner Services & Hospital Stay |
70% |
50% |
| Hospital Services | ||
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Inpatient Room and Board |
70% |
50% |
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Inpatient Rehabilitative Care |
70% |
50% |
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Skilled Nursing Facility Care |
70% |
50% |
| Outpatient Services | ||
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Outpatient Hospital/Facility |
70% |
50% |
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Diagnostic & Therapeutic Radiology and Lab |
70% |
50% |
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CT/PET Scans, Cath Labs, and MRIs |
70% |
50% |
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Emergency Room Visits* |
70% after $100 copay |
50% after $100 copay |
| Other Covered Services | ||
|
Prescription Drugs (no annual max) |
50% (not subject to deductible) |
Not Covered |
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Physical Therapy |
70% |
50% |
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Allergy Injections |
70% |
50% |
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Ambulance Service |
70% |
50% |
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Durable Medical Equipment/Prosthesis |
70% |
50% |
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Home Health, Hospice, and Respite Care |
70% |
50% |
|
Inpatient Mental Health Services |
50% |
50% |
|
Transplant Services |
70% |
Lesser of 50% of billed amount or $100,000 |
| Note: + = Not subject to the annual deductible. Applies to out-of-pocket limit. † = Scheduled benefit ‡ = Payment to providers is based on the PacificSource fee allowance. While participating providers accept the fee allowance as payment in full, nonparticipating providers may not. Services of nonparticipating providers could result in out-of-pocket expense in addition to the percentage indicated. * = Copayment waived if admitted into hospital. *** The above stated out-of-pocket maximum limit amounts apply to the period of January 1 to December 31 of each year. Only participating provider expense applies to the participating provider out-of-pocket limit and only the nonparticipating provider expense applies to the nonparticipating out-of-pocket limit. Once the participating provider out-of-pocket limit has been met, this plan will pay 100% of participating providers’ covered charges for the individual for the rest of that calendar year. Once the nonparticipating provider out-of-pocket limit has been met, this plan will pay 100% of nonparticipating providers’ covered charges for the individual for the rest of the calendar year. Deductibles, prescription drug charges, benefits paid in full, and charges for services of nonparticipating providers in excess of the allowable fee do not accumulate toward the out-of-pocket limit amount. |
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