PacificSource Health Plans
Your policy contains dollar limitations on specific benefits.
| Benefit | Elect Premiere | Elect Preferred | Elect Value Option | Elect HSA |
|---|---|---|---|---|
| Ambulance service | ground 300 miles/year; air $6,000/year |
ground 300 miles/year; air $6,000/year |
ground 300 miles/year; air $6,000/year |
ground 300 miles/year; air $6,000/year |
| Breast exams | One exam/year for women age 18 or older* | One exam/year for women age 18 or older* | One exam/year for women age 18 or older* | One exam/year for women age 18 or older* |
| Cardiac rehabilitation (phase II) | 36 sessions/lifetime | 36 sessions/lifetime | 36 sessions/lifetime | 36 sessions/lifetime |
| Chiropractic manipulation | $1,500 combined maximum | $1,000 combined maximum | Not covered | $1,000 combined maximum |
| Acupuncture care | Not covered | |||
| Naturopathic care | Covered as office visit | Covered as office visit | Not covered | |
| Dietary/nutritional counseling for anorexia or bulimia | 5 visits/lifetime | 5 visits/lifetime | 5 visits/lifetime | 5 visits/lifetime |
| Durable medical equipment | $7,500/lifetime | $7,500/lifetime | $7,500/lifetime | $7,500/lifetime |
| Durable medical equipment: breast pumps | Three months' rental up to $200/lifetime toward rental and/or purchase | Three months' rental up to $200/lifetime toward rental and/or purchase | Three months' rental up to $200/lifetime toward rental and/or purchase | Three months' rental up to $200/lifetime toward rental and/or purchase |
| Durable medical equipment: children's hearing aids** | $4,000 every 48 months | $4,000 every 48 months | $4,000 every 48 months | $4,000 every 48 months |
| Gynecological exams | One exam per year | One exam per year | One exam per year | One exam per year |
| Hospice or respite care | $10,000/lifetime | $10,000/lifetime | $10,000/lifetime | $10,000/lifetime |
| Human papillomavirus (HPV) vaccine | Covered under immunization benefit | Covered under immunization benefit | Covered under immunization benefit | Covered under immunization benefit |
| Mental health treatment (inpatient) |
One day/lifetime | One day/lifetime | One day/lifetime | One day/lifetime |
| Outpatient rehabilitative therapy | 30 visits per year combined physical therapy, occupational therapy, and speech therapy |
30 visits per year combined physical therapy, occupational therapy, and speech therapy |
30 visits per year combined physical therapy, occupational therapy, and speech therapy |
30 visits per year combined physical therapy, occupational therapy, and speech therapy |
| Pelvic exams and pap smear exams | One exam per year for women age 18 to 64* | One exam per year for women age 18 to 64* | One exam per year for women age 18 to 64* | One exam per year for women age 18 to 64* |
| Prescription drug expense | Does not accumulate toward out-of-pocket limit | Does not accumulate toward out-of-pocket limit | Does not accumulate toward out-of-pocket limit | Accumulates toward out-of-pocket limit |
| Routine physical exams | Age 3-21: One exam per year Age 22-34: One exam every four years Age 35-59: One exam every two years Age 60+: One exam per year |
Age 3-21: One exam per year Age 22-34: One exam every four years Age 35-59: One exam every two years Age 60+: One exam per year |
Age 3-21: One exam per year Age 22-34: One exam every four years Age 35-59: One exam every two years Age 60+: One exam per year |
Age 3-21: One exam per year Age 22-34: One exam every four years Age 35-59: One exam every two years Age 60+: One exam per year |
| Skilled nursing facility | 14 days per year*** | 14 days per year*** | 14 days per year*** | 14 days per year*** |
| Tobacco use cessation programs (age 15 or older) |
Two quit attempts/lifetime**** | Two quit attempts/lifetime**** | Two quit attempts/lifetime**** | Two quit attempts/lifetime**** |
| Transplants, travel/housing for recipient | $5,000/transplant | $5,000/transplant | $5,000/transplant | $5,000/transplant |
| Transplants (nonparticipating providers) |
$100,000/lifetime | $100,000/lifetime | $100,000/lifetime | $100,000/lifetime |
| Transplants, nonpar providers | $100,000 | $100,000 | $100,000 | $100,000 |
| Vision, routine exams (every two calendar years) |
One exam | Not covered | Not covered | Not covered |
| Vision, hardware (every two calendar years) |
$200 for frames, lenses, contact lenses | Not covered | Not covered | Not covered |
| Well baby exams | 13 exams in the first 36 months of life***** | 13 exams in the first 36 months of life***** | 13 exams in the first 36 months of life***** | 13 exams in the first 36 months of life***** |
* Service available any time upon referral of a women's healthcare provider.
** Benefits limited to members under age 18 and dependent children age 25 or older who are enrolled in secondary school or an accredited educational institution.
*** Services may be extended to a maximum of 60 days per year when preauthorized by PacificSource.
**** Benefits may be limited to a lifetime maximum value of $500.
***** Includes standard in-hospital exam at birth and related lab tests.
The following exclusions are an overview of treatments, situations, and conditions that are not covered under Elect plans. Only the language of the actual policy is binding.
Abdominoplasty for any indication.
Acupuncture (Elect Value Option).
Admission prior to coverage - Services and supplies for an admission to a hospital, skilled nursing facility, or specialized facility that began before the patient's coverage under the policy.
Benefits not stated - Services and supplies not specifically described as benefits under the policy and/or any endorsement attached hereto.
Biofeedback.
Charges over the allowable fee - Any amount in excess of the allowable fee for a given service or supply.
Chemical dependency treatment.
Chelation therapy (including associated infusions of vitamins and/ or minerals), except as preauthorized by PacificSource for the treatment of selected medical conditions and medically significant heavy metal toxicities.
Chiropractic care (Elect Value Option).
Cosmetic/reconstructive services and supplies - Except as specifically provided for in the policy, services and supplies, including drugs, rendered primarily for cosmetic/reconstructive purposes and any complications as a result of non-covered cosmetic/ reconstructive surgery. Cosmetic/reconstructive services and supplies are those performed primarily to improve the body's appearance and not primarily to restore impaired function of the body, regardless of whether the area to be treated is normal or abnormal.
Criminal conduct - Illness or injury in which a contributing cause was the member's commission of or attempt to commit a felony, including illness or injury in which a contributing cause was being engaged in an illegal occupation.
Custodial care - Care designed essentially to assist a person in maintaining activities of daily living, e.g. services to assist with walking, getting in/out of bed, bathing, dressing, feeding, preparation of meals, homemaker services, special diets, rest cures, and day care. Custodial care is only covered in conjunction with respite care allowed under the policy's hospice benefit.
Dental examinations and treatment - For the purpose of this exclusion, the term "dental examinations and treatment" means services or supplies provided to prevent, diagnose, or treat diseases of the teeth and supporting tissues or structures. This includes services, supplies, hospitalization, anesthesia, dental braces or appliances, or dental care rendered to repair defects that have developed because of tooth loss, or to restore the ability to chew, or dental treatment necessitated by disease.
Drugs or medications, except for those administered while an inpatient in the hospital, and except for those that must be ordered by a physician or other licensed provider prescribing within the scope of his or her license for services covered by the policy and dispensed by a licensed pharmacist.
Equipment commonly used for nonmedical purposes, marketed to the general public and available without a prescription, intended to alter the physical environment, or used primarily in athletic or recreational activities. Items such as the following are specifically excluded from coverage: adjustable power beds sold as furniture; air conditioners; air purifiers; blood pressure monitoring equipment; compression/cooling combination units; computer or electronic devices; computer software for monitoring (including coagulation monitoring), recording, or reporting asthmatic, diabetic, or similar clinical tests or data; conveyances (including scooters) other than conventional wheelchairs; cooling pads; equipment purchased on the Internet; exercise equipment for stretching, conditioning, strengthening, or relief of musculoskeletal symptoms; heating pads; humidifiers, except as part of CPAP apparatus; light boxes; mattress or mattress pads, except for healing of pressure sores; orthopedic shoes; pillows; replacement costs for worn or damaged durable medical equipment that would otherwise be replaceable without charge under warranty or other agreement; spas; saunas; shoe modifications, except when incorporated into a brace or prosthesis; structural alterations in order to prevent, treat, or accommodate a medical condition (including but not limited to grab bars and railings); vehicle alterations in order to prevent, treat, or accommodate a medical condition; whirlpool baths.
Experimental or investigational procedures - Services that are experimental or investigational. An experimental or investigational service is not made eligible for benefits by the fact that other treatment is considered by the member's healthcare provider to be ineffective or not as effective as the service or that the service is prescribed as the most likely to prolong life.
Eye exams, glasses or refraction (Elect Preferred, Elect Value Option and Elect HSA policies only) - Routine eye examinations; the fitting, provision, or replacement of eye glasses, lenses, frames, contact lenses, or subnormal vision aids; and eye exercises, orthoptics, vision therapy, or eye refraction procedures or radial keratotomy intended to correct refractive error.
Eye exam, glasses or refraction (Elect Premiere policies only) - The following items are not covered under this plan's vision benefit: medical and surgical treatment of the eye; special procedures such as orthoptics or vision training; special supplies such as sunglasses (plain or prescription) and subnormal vision aids; tint; plano contact lenses; anti-reflective coatings and scratch resistant coatings; separate charges for contact lens fitting; replacement of lost, stolen, or broken lenses or frames; duplication of spare eyeglasses or any lenses or frames; visual analysis that does not include refraction; eye exams required as a condition of employment, or required by a labor agreement or government body; charges for services or supplies covered in whole or in part under any other medical or vision benefits.
Family planning - Services and supplies for family planning, artificial insemination, in vitro fertilization, diagnosis and treatment of infertility, erectile dysfunction, frigidity, or surgery to reverse voluntary sterilization.
Foot care (routine) - Services and supplies for corns and calluses of the feet, conditions of the toenails other than infection, hypertrophy or hyperplasia of the skin of the feet, and other routine foot care, except when the patient is being reated for mellitus diabetes.
Genetic (DNA) testing - DNA and other genetic tests, except for those tests identified by PacificSource as medically necessary for the diagnosis and standard treatment of specific diseases.
Growth hormone injections or treatments, except to treat documented growth hormone deficiencies.
Immunizations recommended for or in anticipation of exposure through travel or work.
Infertility - Services and supplies, diagnostic laboratory and x-ray studies, surgery, treatment, or prescriptions to diagnose, prevent, or cure infertility or to induce fertility (including Gamete and/or Zygote Interfallopian Transfer; i.e. GIFT or ZIFT), except that medically necessary medication to preserve fertility during treatment with cytotoxic chemotherapy is covered. For purposes of the policy, infertility is defined for males as low sperm counts or the inability to fertilize an egg, and defined for females as the inability to conceive or carry a pregnancy to 12 weeks.
Jaw surgery - Procedures, services, and supplies for developmental or degenerative abnormalities of the jaw, malocclusion, or improving placement of dentures, including dental implants.
Massage, or massage therapy.
Mental health - Outpatient mental health treatment and drugs used primarily in the treatment of mental health are not covered. And except for the initial diagnostic exam by an eligible mental health provider, PacificSource will not pay benefits for services and supplies from a mental health or other healthcare provider for the following diagnoses and/or diagnostic categories as listed in the fourth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV): learning disorders, motor skills disorders, communication disorders, disruptive behavior disorders, factitious disorders, sexual and gender identity disorders, impulse control disorders, paraphilias except for pedophilia, relational problems, caffeine-related disorders, nicotinerelated disorders, and the category of "additional conditions that may be a focus of clinical attention." This exclusion applies to learning disorders, sensory integration disorders, and conduct disorders whether or not associated with either attention deficit/hyperactivity disorder or adjustment reactions.
The following treatment types are also excluded, regardless of diagnosis:
sensory integration training, biofeedback, hypnotherapy, academic skills training, narcosynthesis, and social skills training. Recreation therapy is covered only as a part of mental health inpatient or residential admission.
The following are also excluded: courtmandated diversion and/or chemical dependency education classes; courtmandated psychological evaluations for child custody determinations; voluntary mutual support groups such as Alcoholics Anonymous; adolescent wilderness treatment programs; mental examinations for the purpose of adjudication of legal rights; psychological testing and evaluations not provided as an adjunct to treatment or diagnosis of a mental disorder; treatments or services for career counseling, personal growth, relaxation, stress management, parenting skills, or family education; assertiveness training; image therapy; sensory movement group therapy; marathon group therapy; sensitivity training; and psychological evaluation for sexual dysfunction or inadequacy.
Motion analysis including video taping and 3-D kinematics, dynamic surface and fine wire electromyography, including physician review.
Myeloablative high dose chemotherapy except when the related transplant is specifically covered under the transplantation provisions of the policy.
Naturopathic/homeopathic services or supplies (Elect Value Option).
Obesity or weight control - Surgery or other related services or supplies provided for weight control or obesity (including all categories of obesity), whether or not there are other medical conditions related to or caused by obesity. The exclusion also includes services or supplies used for weight loss, such as food supplementation programs and behavior modification programs, regardless of the medical conditions that may be caused or exacerbated by excess weight, and self-help or training programs for weight control.
Orthognathic surgery - Services and supplies to augment or reduce the upper or lower jaw, except as specifically provided for in the policy.
Osteopathic manipulation, except for treatment of disorders of the musculoskeletal system.
Panniculectomy for any indication.
Physical examinations - Routine physical or eye examinations required for administrative purposes such as participation in athletics, admission to school, or by an employer.
Providers (ineligible) - An individual, organization, facility or program is not eligible for reimbursement for services or supplies, regardless of whether this policy includes benefits for such services or supplies, unless the individual, organization, facility, or program is licensed by the state in which services are provided as an independent practitioner, hospital, ambulatory surgical center, skilled nursing facility, durable medical equipment supplier, or mental and/ or chemical healthcare facility. And, to the extent PacificSource maintains credentialing requirements the practitioner or facility must satisfy those requirements.
Rehabilitation - Functional capacity evaluations, work hardening programs, vocational rehabilitation, community reintegration services, and driving evaluations and training programs.
Routine services and supplies - Services, supplies, and equipment not involved in diagnosis or treatment but provided primarily for the comfort, convenience, cosmetic purpose, environmental control, or education of a patient or for the processing of records or claims. These include but are not limited to: charges for telephone consultations, missed appointments, completion of claim forms, or reports requested by PacificSource in order to process claims; appliances, such as air conditioners, humidifiers, air filters, whirlpools, hot tubs, heat lamps, or tanning lights; private nursing service, or personal items such as telephones, televisions, and guest meals in a hospital or skilled nursing facility; maintenance supplies and equipment not unique to medical care.
Scheduled and/or non-emergent medical care outside the United States.
Screening tests - Services and supplies, including imaging and screening exams performed for the sole purpose of screening and not associated with specific diagnoses and/or signs and symptoms of disease or of abnormalities on prior testing (including but not limited to total body CT imaging, CT colonography and bone density testing), except to the extent covered under the policy's preventive care benefits.
Services otherwise available - These include but are not limited to: services or supplies for which payment could be obtained in whole or in part if the member applied for payment under any city, county, state, or federal law; and services or supplies the member could have received in a hospital or program operated by a federal government agency or authority. Covered expenses for services or supplies furnished to a member by the Veterans' Administration of the United States that are not service-related are eligible for payment according to the terms of the policy. This exclusion does not apply to covered services provided through Medicaid or by any hospital owned or operated by the State of Oregon or any state-approved community mental health and developmental disability program.
Services or supplies for which no charge is made or which the member is not legally required to pay, or which a provider or facility is not licensed to provide even though the service or supply may otherwise be eligible. This includes services provided by the member, or by an immediate family member.
Sexual disorders - Services or supplies for the treatment of sexual dysfunction or inadequacy.
Sex reassignment - Procedures, services or supplies (including genderreassignment drug therapies in a pre-surgery situation) related to a sex reassignment.
Sleep apnea/sleeping disorders and/or sleep studies - Services or supplies for the treatment of sleep apnea or other sleeping disorders including expense for sleep studies.
Snoring - Services or supplies for the diagnosis or treatment of snoring and/ or upper airway resistance disorders, including somnoplasty.
Temporomandibular joint - Advice or treatment, including physical therapy and/or oromyofascial therapy, either directly or indirectly for temporomandibular joint dysfunction, myofascial pain, or any related appliances.
Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers' compensation - Any services or supplies for illness or injury for which a third party is responsible or which are payable by such third party or which are payable pursuant to applicable workers' compensation laws, motor vehicle liability, uninsured motorist, underinsured motorist, and personal injury protection insurance and any other liability and voluntary medical payment insurance to the extent of any recovery received from or on behalf of such sources.
Training or self-help programs - General fitness exercise programs, and programs that teach a person how to use durable medical equipment or care for a family member. Also excluded are health or fitness club services or memberships and instruction programs, including but not limited to those to learn to self-administer drugs or nutrition, except as specifically provided for in the policy.
Transplants - Any services, treatments, or supplies for the transplantation of bone marrow or peripheral blood stem cells or any human body organ or tissue, except as expressly provided under the policy's provisions for covered transplantation expenses.
Treatment after insurance ends - Services or supplies a member receives after the member's insurance under the policy ends.
Treatment not medically necessary - Services or supplies that are not medically necessary for the diagnosis or treatment of an illness or injury.
Treatment prior to enrollment - Services or supplies a member received before enrolled under the policy.
Treatment while incarcerated - Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison.
Unwilling to release information - Charges for services or supplies for which a member is unwilling to release medical information necessary to determine eligibility for payment.
War-related conditions - The treatment of any condition caused by or arising out of an act of war, armed invasion, or aggression, or while in the service of the armed forces.
