| |
Annual Deductible |
Out-of-Pocket Limit (per person) |
Individual Annual Deductible &
Out-of-Pocket (OOP) Limit
(Limit includes the deductible) |
$500 per person / $1,500 per family |
$5,000 |
| $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
(Minus the amount of the plan’s deductible) |
$10,000 per person ($500 - $5,000 deductible)
$15,000 per person ($7,500 deductible)
$20,000 per person ($10,000 deductible) |
| Maximum Annual Benefit (per person) |
$2,000,000 |
Accident Benefit
(accident-related covered expenses) |
The first $2,500 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 Providers |
Non-Participating Providers ‡ |
| Preventive Care |
|
|
| Well Baby Care |
100% + |
50% + |
| Routine Physicals and Preventive Care Exams |
100% + † |
50%+ † |
| Routine Gynecological Exams |
100% + |
50%+ |
| Immunizations |
100% + |
50%+ |
| Professional Services |
| Office and Home Visits |
100% after $30 copay + |
50% after $30 copay + |
| Surgery |
70% |
50% |
| Chiropractic Manipulation |
100% after $30 copay + |
50% |
| Acupuncture |
| Naturopathic Care |
100% after $30 copay + |
50% after $30 copay + |
| Urgent Care Visits |
100% after $30 copay + |
50% after $30 copay + |
| Maternity Care |
| Practitioner Services and Hospital Stay |
70% |
50% |
| Hospital Services |
| Inpatient Room and Board |
70% |
50% |
| Inpatient Rehabilitative Care |
70% |
50% |
| Inpatient Rehabilitative Care |
70% |
50% |
| Outpatient Services |
| Outpatient Hospital/Facility |
70% |
50% |
| Diagnostic & Therapeutic Radiology and Lab |
70% |
50% |
| Advanced Imaging |
70% |
50% |
| Emergency Room Visits |
70%after $100 copay
(copay waived if admitted to hospital) |
50% after $100 copay
(copay waived if admitted to the hospital) |
| Other Covered Services |
| Prescription Drugs |
Incentive drugs: $4 copay +
Generic and Preferred brand name drugs: 50% + |
Not Covered |
| Outpatient Rehabilitative Care |
70% |
50% |
| Allergy Injections |
70% |
50% |
| Ambulance Service |
70% |
50% |
| Durable Medical Equipment/Prosthetics |
70% |
50% |
| Home Health, Hospice, and Respite Care |
70% |
50% |
| Inpatient Mental Health Services |
70% |
50% |
| Transplant Services |
70% |
Lesser of 50% of billed amount or $100,000 |
Note:
+ = Not subject to the annual deductible. Applies to out-of-pocket
limit.
* = 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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