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Index | Exclusions
& Limitations | Eligibility | Locate
Providers | Application
Plan Benefits:
Elect Premiere | Elect Preferred | Elect HSA | Elect
Value
Plan Rates:
Elect Premiere | Elect Preferred | Elect HSA | Elect Value
Oregon Health Insurance Plans
LifeWise Health Plans of Oregon
Regence BC BS of OR
ODS Health Plans
PacificSource
Providence Health Plans
HealthNet of Oregon
Kaiser Permanente
Oregon Medical Insurance Pool
Medicare Supplement Plans
- Medicare 101
- Medicare Plans Overview
- Medicare Information Request
- Medicare Supplements
- Medicare Part D
- Columbian Mutual
- Gerber Life
- HealthNet
- Humana
- Lifewise
- Loyal American
- ODS Senior Select
- Regence
- Sentinel Life
- Sterling
- United of Omaha
- UCT
- UnitedHealthcare
- Woodmen
Medicare Advantage Plans
- Medicare Advantage Overview
- Medicare Information Request
- HealthNet
- ODS
- PacificSource
- Providence
- Regence
- Trillium
- UnitedHealthcare
Other Insurance
Oregon Medical Insurance > PacificSource Health Plans > Elect Premiere Benefits
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Elect Premiere |
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|
Maximum Annual Benefit (per person) |
$2,000,000 |
|
|
Annual Deductible |
Out-of-Pocket Limit (per person) | |
| Individual Annual Deductible &
Out-of-Pocket (OOP) Limit (Limit includes the deductible) |
$1,000 per person / $3,000 per family |
$5,000 |
|
$2,500 per person / $7,500 per family |
$5,000 | |
|
$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 ($1,000—$5,000
deductible) $15,000 per person ($7,500 deductible) $20,000 per person ($10,000 deductible) |
|
|
Accident Benefit (accident-related covered expenses) |
The first $5,000 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. | |
| Preventive Care | Participating Providers | Non-Participating Providers ‡ |
|
Well Baby Care |
100% + |
60% + |
|
Routine Physicals and Preventive Care Exams |
100% + † |
60% + † |
|
Routine Gynecological Exams |
100% + |
60% + |
|
Immunizations |
100% + |
60% + |
| Professional Services | ||
| Office and Home Visits | 100% after $25 copay + |
60% after $25 copay + |
Surgery |
80% |
60% |
| Chiropractic Manipulation | 100% after $25 copay + |
60% after $25 copay + |
Acupuncture |
||
Naturopathic Care |
100% after $25 copay + | 60% after $25 copay + |
|
Urgent Care Visits |
100% after $25 copay + | 60% after $25 copay + |
| Maternity Care | ||
Practitioner Services and Hospital Stay |
80% |
60% |
| Hospital Services | ||
Inpatient Room and Board |
80% |
60% |
Inpatient Rehabilitative Care |
80% |
60% |
Inpatient Rehabilitative Care |
80% |
60% |
| Outpatient Services | ||
Outpatient Hospital/Facility |
80% |
60% |
Diagnostic & Therapeutic Radiology and Lab |
80% |
60% |
Advanced Imaging |
80% |
60% |
Emergency Room Visits |
80% after $100 copay |
60%after $100 copay |
| Other Covered Services | ||
|
Prescription Drugs |
Incentive drugs: $4 copay + Generic drugs: $10 copay + Preferred brand name drugs: 50% + |
Not Covered |
Outpatient Rehabilitative Care |
80% |
60% |
Allergy Injections |
80% |
60% |
Ambulance Service |
80% |
60% |
Durable Medical Equipment/Prosthetics |
80% |
60% |
|
Home Health, Hospice, and Respite Care |
80% |
60% |
Inpatient Mental Health Services |
80% |
60% |
Vision (per 2 calendar years) |
Exam: 100% after $25 copay + |
Exam: 60% after $25 copay + |
|
Transplant Services |
80% |
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. *** 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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