| |
Elect Value Option |
|
Maximum Lifetime Benefit |
$2,000,000 |
| |
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)
|
$2,500 per person / $7,500 per family |
$7,500 |
|
$5,000 per person / $15,000 per family |
$10,000 |
|
$7,500 per person / $22,500 per family |
$12,500 |
|
$10,000 per person / $30,000 per family |
$15,000 |
|
Out-of-Pocket Limit, Nonparticipating Provider
(Minus the amount of the plan’s deductible) |
$10,000 per person ($2,500 & $5,000
deductible);
$20,000 per person ($7,500 & $10,000 deductible) |
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
‡ |
|
Well Baby Care |
Not covered |
50% |
|
Routine Physicals and Preventive Care Exams |
Not covered |
Not covered |
|
Routine Gynecological Exams |
100% after $35 copay + |
50% after $35 copay + |
|
Immunizations |
60% |
50% |
| Professional Services |
| Office and Home Visits |
60% |
50% |
|
Surgery |
60% |
50% |
|
Chiropractic Manipulation |
Not covered |
Not covered |
Acupuncture |
Not covered |
Not covered |
|
Naturopathic Care |
Not covered |
Not covered |
Urgent Care Center Visits |
60% |
50% |
| Maternity Care |
|
Practitioner Services & Hospital Stay |
60% |
50% |
| Hospital Services |
|
Inpatient Room and Board |
60% |
50% |
|
Inpatient Rehabilitative Care |
60% |
50% |
|
Skilled Nursing Facility Care |
60% |
50% |
| Outpatient Services |
|
Outpatient Hospital/Facility |
60% |
50% |
|
Diagnostic & Therapeutic Radiology and Lab |
60% |
50% |
|
CT/PET Scans, Cath Labs, and MRIs |
60% |
50% |
|
Emergency Room Visits |
60% |
50% |
| Other Covered Services |
|
Prescription Drugs |
50% |
Not Covered |
|
Physical Therapy |
60% |
50% |
|
Allergy Injections |
60% |
50% |
|
Ambulance Service |
60% |
50% |
|
Durable Medical Equipment/Prosthesis |
60% |
50% |
|
Home Health, Hospice, and Respite Care |
60% |
50% |
|
Inpatient Mental Health Services |
60% |
50% |
|
Transplant Services |
60% |
Lesser of 50% of billed amount or $100,000 |
Note:
+ = Not subject to the annual deductible. Applies to out-of-pocket
limit.
‡ = 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. |
Download Request 
