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Oregon Medical Insurance > PacificSource Health Plans > Elect FlexPerks Benefits

PacificSource

 
Elect HSA (HSA-Qualified)
Maximum Annual Benefit (per person)
$2,000,000
 
Annual Deductible
Out-of-Pocket Limit(individual / family)
Participating Provider Annual Deductible & Out-of-Pocket (OOP) Limit
(Copayments and deductible apply to out-of-pocket limit)
$1,500 per person / $3,000 per family
$5,000/$10,000
$2,000 per person / $4,000 per family
$5,000/$10,000
$3,000 per person / $6,000 per family
$5,800/$11,600
$5,000 per person / $10,000 per family
$5,000/$10,000
Out-of-Pocket Limit, Nonparticipating Provider
(Minus the amount of the plan’s deductible)
$10,000 per person
Accident Benefit
(accident-related covered expenses)
The first $1,000 of covered expense within 90 days of an accident is paid at 100% and is not subject to the deductible. The balance is covered as shown below.
Deductible Option:
$1,500, $2,000 or $3,000
$5,000
Provider Type:
Participating
Nonpar ‡
Participating
Nonpar ‡
Preventive Care

Well Baby Care

100% +
40% +
100% +
50%

Routine Physicals and Preventive Care Exams

100% + †
40% + †
100% + †
50% †

Routine Gynecological Exams

100% +
40% +
100% +
50%

Immunizations

100% +
40% +
100% +
50%
Professional Services
Office and Home Visits
50%
40%
100%
50%

Surgery
50%
40%
100%
50%
Chiropractic Manipulation
50%
 40%
100%
 50%

Acupuncture

Naturopathic Care

Urgent Care Center Visits

50%
40%
100%
50%
Maternity Care

Practitioner Services and Hospital Stay
50%
40%
100%
50%
Hospital Services

Inpatient Room and Board
50%
40%
100%
50%

Inpatient Rehabilitative Care
50%
40%
100%
50%

Skilled Nursing Facility Care
50%
40%
100%
50%
Outpatient Services

Outpatient Hospital/Facility
50%
40%
100%
50%

Diagnostic & Therapeutic Radiology and Lab
50%
40%
100%
50%

Advanced Imaging
50%
40%
100%
50%

Emergency Room Visits
50%
40%*
100%
50%*
Other Covered Services

Prescription Drugs
50%
Not covered
100%
Not covered

Outpatient Rehabilitative Services
50%
40%
100%
50%

Allergy Injections
50%
40%
100%
50%

Ambulance Service

50%
40%
100%
50%

Durable Medical Equipment/Prosthetics
50%
40%
100%
50%

Home Health, Hospice, and Respite Care
50%
40%
100%
50%

Inpatient Mental Health
50%
40%
100%
50%

Transplant Services
50%
Lesser of 50% of billed amount or $100,000
100%
Lesser of 50% of billed amount or $100,000
Note:
+ = Not subject to the annual deductible.
* = Nonparticipating providers are paid at participating percentages in true medical emergencies.
† = 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.

 

 

 
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