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Oregon Medical Insurance > PacificSource Health Plans > Elect FlexPerks Benefits


PacificSource

PacificSource Elect HSA Benefits
  $1,500, $2,000 or $3,000 Deductible $5,000 Deductible
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.
  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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