PacificSource Health Plans

Plan Network

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Plan Coverage
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Doctor Visits

Primary Care
First 4 visits free
$50
Specialist
$50
Preventative Care
No charge

Prescriptions

Generic Drugs
$10
Brand Drugs
$50
Brand Drugs (Non-Preferred)
$75 after deductible
Specialty Drugs
$250 after deductible

Hospital

Emergency Room
$0 after deductible
Ambulance
$0 after deductible
Hospital Stay (Facility)
$0 per Stay after deductible
Hospital Stay (Physician)
$0 after deductible
Outpatient Procedure (Facility)
$0 after deductible
Outpatient Procedure (Physician)
$0 after deductible

Pregnancy

Delivery
$0 after deductible
Well Baby Visits
No charge

Mental Health

Outpatient Services
$50
Psychiatric Hospital Stay
$0 after deductible

Diagnostics / Labs / Imaging

X-Rays
$0 after deductible
CT Scans, Pet Scans and MRIs
$0 after deductible
Lab Tests
$0 after deductible

Free Preventative Care

If you use an in-network doctor, this plan will provide all preventative care services at no cost.

List of covered services

Out of Network

If you use out-of-network providers under this plan, you may have to pay more or even full price. Out of Network care doesn't count towards your deductible and maximum out-of-pocket.