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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
Oregon Medical Insurance > PacificSource Health Plans > Elect Premiere Benefits
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Elect Premiere |
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Maximum Lifetime Benefit |
$2,000,000 |
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Annual Deductible |
Out-of-Pocket Limit (per person) | |
| Annual Deductible &
Participating Provider Out-of-Pocket Limit |
$500 per person / $1,500 per family | $5,000 |
| $750 per person / $2,250 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 | |
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$7,500 per person / $22,500 per family |
$15,000 | |
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Out-of-Pocket Limit, Nonparticipating Provider |
$10,000 per person ($500—$5,000
deductible) $15,000 per person ($7,500 deductible) |
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| Accident Benefit | Deductible waived and 100% benefit for first $5,000 of accident-related covered expenses within 90 days | |
| Preventive Care | Participating Providers | Non-Participating Providers ‡ |
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Well Baby Care |
100% after $25 copay + |
60% after $25 copay + |
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Routine Physicals and Preventive Care Exams |
100% after $25 copay + † |
60% after $25 copay + † |
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Routine Gynecological Exams |
100% after $25 copay + |
60% after $25 copay + |
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Immunizations |
80% + |
60% + |
| Professional Services | ||
| Office and Home Visits | 100% after $25 copay + |
60% after $25 copay + |
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Surgery |
80% |
60% |
| Chiropractic Manipulation | 100% after $25 copay + (15 Combined visits) |
60% after $25 copay + |
Acupuncture |
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Naturopathic Care |
100% after $25 copay + | 60% after $25 copay + |
| Maternity Care | ||
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Practitioner Services |
80% |
60% |
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Hospital Stay |
80% |
60% |
| Hospital Services | ||
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Inpatient Room and Board |
80% |
60% |
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Inpatient Rehabilitative Care |
80% |
60% |
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Skilled Nursing Facility Care |
80% |
60% |
| Outpatient Services | ||
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Outpatient Hospital/Facility |
80% |
60% |
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Diagnostic & Therapeutic Radiology and Lab |
80% |
60% |
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CT/PET Scans, Cath Labs, and MRIs |
80% |
60% |
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Emergency Room Visits* |
80% after $100 copay |
60% |
Urgent Care Center Visits |
80% after $25 copay + |
60% after $25 copay + |
| Other Covered Services | ||
|
Prescription Drugs (not subject to deductible) |
Generic drugs: 100% after $15 copay Brand drugs: 50% |
Not Covered |
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Physical Therapy |
80% |
60% |
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Allergy Injections |
80% |
60% |
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Ambulance Service |
80% |
60% |
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Durable Medical Equipment/Prosthesis |
80% |
60% |
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Home Health, Hospice, and Respite Care |
80% |
60% |
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Inpatient Mental Health Services |
60% |
60% |
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Transplant Services |
80% |
Lesser of 60% 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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