Core Silver 4500
PacificSource Health Plans
Plan overview
Medical deductible
Individual: $4500
Family: $9000
Per Person: $4500
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $9750
Family: $19500
Per Person: $9750
Office visit
Primary Doctor
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
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: $60.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
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: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
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: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Specialty drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
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.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
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
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
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
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit: Visit(s) per Benefit Period
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.
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).