Sample Plan Summaries for Oregon

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

Preferred Plan Limitations
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

Effective October 1, 2010:
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

Preferred Plan Limitations
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%

Effective October 1, 2010:
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

Preferred Plan Limitations
80+300	80+1000	50/3750
80+500	80+1500	50/5000
80+750	80+2000	70/3500
	80+2500

Effective October 1, 2010:
80+300	80+1000	50/3750
80+500	80+1500	50/5000
80+750	80+2000	70/3500
	80+2500

Preferred CoPay Plans

Preferred Plan Limitations
15/200D	25/200D	15/50%

Effective October 1, 2010:
15/200D	25/200D

Preferred HSA Plans

Preferred Plan Limitations
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

Effective October 1, 2010:
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)

BHP Plan Limitations
BHP

Effective October 1, 2010:
BHP

Prime Plans

Prime/Choice Plan Limitations
15/200D	500+25
25/200D	1000+35

Effective October 1, 2010:
15/200D	500+25
25/200D	1000+35

Choice Plans

Prime/Choice Plan Limitations
15/200D	25/200D

Effective October 1, 2010:
15/200D	25/200D

Optional Benefits

Prescription Drug Plans

Tiered 10/20/40	Rx 50%	$200 Ded. Tiered 15/30/50
Tiered 15/30/50	Rx 15/50% $5000	Rx BHP
Tiered Value Plan 10/50/75

Dental Plans

Indemnity Plans	Dental Advantage Premier (PPO)	Dental Advantage (PPO)
Preventive $25/$1,000	80/80/80/50 25/1000	80/80/50/50 25/1000
Preventive $50/$1,000	80/80/80/50 25/1500	80/80/50/50 25/1500
Preventive $25/$1,500	80/80/80/50 25/2000	80/80/50/50 25/2000
Preventive $50/$1,500	80/80/80/50 50/1000	80/80/50/50 50/1000
Comp $25/$1,000	80/80/80/50 50/1500	80/80/50/50 50/1500
Comp $50/$1,000	80/80/80/50 50/2000	80/80/50/50 50/2000
Comp $25/$1,500	100/80/80/50 25/1000	100/80/50/50 25/1000
Comp $50/$1,500	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 Plus	Vision Exam Only

Alternative Care and Chiropractic Care Plans

Chiro Plus $500 max	Alt Care $500 max	Alt/Chiro $500 max
Chiro Plus $1,000 max	Alt Care $1,000 max	Alt/Chiro $1,000 max
Chiro Plus $1,500 max	Alt Care $1,500 max	Alt/Chiro $1,500 max

Life and Disability Plans

$10,000	$10,000 with dependent option
$20,000	$20,000 with dependent option
$30,000	$30,000 with dependent option
$40,000	$40,000 with dependent option
$50,000	$50,000 with dependent option

Other Optional Benefits

Additional Accident Benefit

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For group-specific benefit summaries, please contact your regional PacificSource office

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Last updated 8/24/2010