Sample Plan Summaries en Español

The sample summaries and plan limitations below are approved PacificSource employer plan designs. At enrollment, members receive customized benefit books showing their specific benefits, lifetime maximums, and any optional coverage provided by the employer. For group-specific member benefit summaries, or previously offered summaries, contact your regional PacificSource office.

Group Medical Plans

Preferred CoDeduct Plans

Plan Limitations for plans effective July 1, 2011

Effective July 1, 2011:
300+15	1000+15	2000+35
300+25	1000+25	2000+35/70%
500+15	1000+35	2000+50
500+25	1000+50	2500+25
500+35	1500+25	2500+35
750+15	1500+35	2500+50
750+25	1500+50	3000+35/70%
750+35	2000+25

Preferred CoDeduct Value Plans

Note: A few plans will be updated effective January 1, 2012. Those plans are:

Plan Limitations for plans effective July 1, 2011

Effective July 1, 2011:
CDV 300+35	CDV 1500+25	CDV 3000+25
CDV 300+35/70%	CDV 1500+25/70%	CDV 3000+25/70%
CDV 300+50	CDV 1500+35	CDV 3000+35
CDV 300+50/70%	CDV 1500+35/70%	CDV 3000+35/70%
CDV 500+35	CDV 1500+50	CDV 3000+50
CDV 500+35/70%	CDV 1500+50/70%	CDV 3000+50/70%
CDV 500+50	CDV 2000+25	CDV 5000+25
CDV 500+50/70%	CDV 2000+25/70%	CDV 5000+25/70%
CDV 750+25	CDV 2000+35	CDV 5000+35
CDV 750+25/70%	CDV 2000+35/70%	CDV 5000+35/70%
CDV 750+35	CDV 2000+50	CDV 5000+50
CDV 750+35/70%	CDV 2000+50/70%	CDV 5000+50/70%
CDV 750+50	CDV 2500+25	CDV 7500+25
CDV 750+50/70%	CDV 2500+25/70%	CDV 7500+25/70%
CDV 1000+25	CDV 2500+35	CDV 7500+35
CDV 1000+25/70%	CDV 2500+35/70%	CDV 7500+35/70%
CDV 1000+35	CDV 2500+50	CDV 7500+50
CDV 1000+35/70%	CDV 2500+50/70%	CDV 7500+50/70%
CDV 1000+50
CDV 1000+50/70%

Diamond $300 and $500 deductible plans available for small groups only.
Star $25 copay plans available for large groups only.

Preferred Deductible and Percentage Plans

Plan Limitations for plans effective July 1, 2011

Effective July 1, 2011:
80+300	80+1000	50/3750
80+500	80+1500	50/5000
80+750	80+2000	70/3500
	80+2000

Preferred CoPay Plans

Plan Limitations for plans effective July 1, 2011

Effective July 1, 2011:
15/200D	25/200D

Preferred HSA Plans

Effective July 1, 2011:
No Rx Coverage:	Rx Subject to Deductible:
HSA 80+1500	HSA 80+1500+Rx
HSA 80+2000	HSA 80+2000+Rx
HSA 80+3000	HSA 80+3000+Rx
HSA 5000	HSA 5000+Rx

Preferred Basic Health Plan (BHP)

Effective July 1, 2011:
BHP

Choice Plans

Plan Limitations for plans effective July 1, 2011

Effective July 1, 2011:
15/200D	25/200D

Optional Benefits

Prescription Drug Plans

Tiered 10/35/60
Tiered 15/30/50
Tiered Value Plan 10/50/75
Tiered Incentive 4/10/35/60
Tiered 15/200+30/50

Dental Plans

Effective July 1, 2011:
Indemnity Plans	Dental Advantage Premier (PPO)	Dental Advantage (PPO)
Preventive 25/1000	80/80/80/50 25/1000	80/80/50/50 25/1000
Preventive 50/1000	80/80/80/50 25/1500	80/80/50/50 25/1500
Preventive 25/1500	80/80/80/50 25/2000	80/80/50/50 25/2000
Preventive 50/1500	80/80/80/50 50/1000	80/80/50/50 50/1000
Comprehensive 25/1000	80/80/80/50 50/1500	80/80/50/50 50/1500
Comprehensive 50/1000	80/80/80/50 50/2000	80/80/50/50 50/2000
Comprehensive 25/1500	100/80/80/50 25/1000	100/80/50/50 25/1000
Comprehensive 50/1500	100/80/80/50 25/1500	100/80/50/50 25/1500
Orthodontia	100/80/80/50 25/2000	100/80/50/50 25/2000
	100/80/80/50 50/1000	100/80/50/50 50/1000
	100/80/80/50 50/1500	100/80/50/50 50/1500
	100/80/80/50 50/2000	100/80/50/50 50/2000

Diamond Available on a stand-alone basis for groups with 2 to 9 enrolled employees

Vision Plans

Vision 10/150	Vision 10/300
Vision Exam-Only

Alternative Care and Chiropractic Care Plans

Alt/Chiro $500 max	Alt/Chiro $2,000 max
Alt/Chiro $1,000 max	Alt/Chiro $2,500 max (large groups only)
Alt/Chiro $1,500 max

Other Optional Benefits

Additional Accident Benefit

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Last updated 3/23/2012

Sample Plan Summaries en Español

Group Medical Plans

Preferred CoDeduct Plans

Preferred CoDeduct Value Plans

Preferred Deductible and Percentage Plans

Preferred CoPay Plans

Preferred HSA Plans

Preferred Basic Health Plan (BHP)

Choice Plans

Optional Benefits

Prescription Drug Plans

Dental Plans

Indemnity Plans

Dental Advantage Premier (PPO)

Dental Advantage (PPO)

Vision Plans

Alternative Care and Chiropractic Care Plans

Other Optional Benefits

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