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Oregon-Gateway-GraphicSample 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 CoDeduct Value Plans

Plan Limitations for plans effective July 1, 2011 or later

Preventive Care Limits for Preferred, Prime, and Choice

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

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

Plan Limitations for plans effective July 1, 2011 or later

Preventive Care Limits for Preferred, Prime, and Choice

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

 

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

 

Preferred HSA Plans

Plan Limitations for plans effective July 1, 2011 or later

Preventive Care Limits for Preferred, Prime, and Choice

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  

 

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)

Preventive Care Limits for BHP

Effective July 1, 2011:
BHP    

 

BHP Plan Limitations for plans effective October 1, 2010 or later

Effective October 1, 2010:
BHP    

 

Prime Plans

Plan Limitations for plans effective July 1, 2011 or later

Preventive Care Limits for Preferred, Prime, and Choice

Effective July 1, 2011:
15/200D 500+25  
25/200D 1000+35  

 

Choice Plans

Plan Limitations for plans effective July 1, 2011 or later

Preventive Care Limits for Preferred, Prime, and Choice

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

 

Optional Benefits

Prescription Drug Plans

Dental Plans

Effective July 1, 2011:

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 Diamond
Comp $25/$1,000 80/80/80/50 50/1500 80/80/50/50 50/1500 Diamond
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 Diamond
  100/80/80/50 50/1500 100/80/50/50 50/1500 Diamond
  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

Effective prior to July 1, 2011:

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 Diamond
Comp $25/$1,000 80/80/80/50 50/1500 80/80/50/50 50/1500 Diamond
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 Diamond
  100/80/80/50 50/1500 100/80/50/50 50/1500 Diamond
  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

Alternative Care and Chiropractic Care Plans

Effective July 1, 2011:
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    

 

Life and Disability Plans

Other Optional Benefits

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Last updated 2/3/2012
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