PacificSource Health Plans

PacificSource Oregon Standard Bronze Plan NAV

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Combined Medical and Drug Deductible	Individual: $9,200.00 Family: $18400 Per Person: $9200
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Primary Doctor	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Exclusions: Missed appointments and get acquainted visits. See policy for more information. Benefit Explanation: $5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.
Specialist	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered Exclusions: Missed appointments and get acquainted visits. See policy for more information.

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $35 max out of pocket for 30 day supply prior to deductible. See policy for more information.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $35 max out of pocket for 30 day supply prior to deductible. See policy for more information.
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Certain drugs may fall under a higher or lower cost sharing amount than is listed here. $500 cap per script for Standard Gold Plans. See policy for more information.

Hospital Services

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Exclusions: Charges for inpatient stays that began before you were covered by this plan.
Benefit Explanation: Charges for a hospital room are covered up to the hospital?s semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.

Inpatient Services

Emergency Room

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Exclusions: Charges for inpatient stays that began before you were covered by this plan.
Benefit Explanation: Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.

Urgent Care Facility

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Benefit Period
Exclusions: Orthoptics, vision therapy, or other services to correct refractive error.
Benefit Explanation: Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. In network: Covered in Full. Out of network: No charge up to $40 maximum, and the remaining cost is member responsibility.

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered