PacificSource Cascade Gold

14057WA0060009
Gold
PPO

PacificSource Cascade Gold is a Gold PPO plan by PacificSource Health Plans.

Locations

PacificSource Cascade Gold is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of PacificSource Cascade Gold 14057WA0060009.
Insurer: PacificSource Health Plans
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 14057WA0060009

Cost-Sharing Overview

PacificSource Cascade Gold offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for PacificSource Cascade Gold?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

PacificSource Cascade Gold offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Diabetes, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what PacificSource Cascade Gold covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Care Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Out-of-Network Providers
National Network: Yes

Additional Benefits and Cost-Sharing

PacificSource Cascade Gold includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year Coverage for habilitative services is limited to 30-inpatient days/year. Coverage for habilitative services is limited to 30-outpatient visits/year. See policy for more information.Other Law/Regulation
Orthodontia – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No130 Visit(s) per Year
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year Coverage is limited to 30-inpatient days/year. Outpatient rehabilitation, combined physical, occupational, and speech therapy, services is limited to 30-outpatient visits per year.
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Check-Up for Children
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. Per day copay, limit of 5 copays per stay.
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Days per Month Coverage is limited to a 90-day supply retail or 90-day supply mail order per fill or refill. See policy for more information.Other Law/Regulation
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Days per Year Coverage is limited to 60-inpatient days/year.
Bariatric Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Per day copay, limit of 5 copays per stay. Copay for All Inpatient Hospital Services includes the facility fee and professional service charges.
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year See policy for more information.Additional EHB Benefit
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No12 Visit(s) per Year
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Days per Month Coverage is limited to a 90-day supply retail or 90-day supply mail order per fill or refill. See policy for more information.Other Law/Regulation
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No14 Days per Lifetime Respite care is subject to a maximum of 14 days per lifetime when arranged by an attending Provider. The Enrollee must be enrolled in a hospice program to be eligible for respite care benefits.Additional EHB Benefit
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Charges and coverage for Inpatient Physician and Surgical Services are included under the benefit for Inpatient Hospital Services.
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No12 Visit(s) per Year Additional EHB Benefit
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan.
Diabetes Care Management
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Inherited Metabolic Disorder – PKU
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. Per day copay, limit of 5 copays per stay.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Days per Month Coverage is limited to a 90-day supply retail or 90-day supply mail order per fill or refill. See policy for more information.Other Law/Regulation
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Abortion for Which Public Funding is Prohibited
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Days per Month First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy. See policy for more information.Other Law/Regulation
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Cochlear Implants must be covered as they are covered by the state base benchmark plan.
Routine Foot Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered for patients with diabetes mellitus.Not EHB
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Not EHB
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year Coverage is limited to 30-inpatient days/year. Outpatient rehabilitation, combined physical, occupational, and speech therapy, services is limited to 30-outpatient visits per year.
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered under the base benchmark plan; covered under applicable benefit (such as office visit).
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year See policy for more information.
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per Year Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. See policy for more information.
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered under the base benchmark plan.
Infertility Treatment
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Cosmetic Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Procedure(s) per Episode Additional EHB Benefit
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Not EHB
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Per day copay, limit of 5 copays per stay.
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered under applicable benefit (such as office visit).
Dental Anesthesia
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No

Free Preventive Services

There is no copayment or coinsurance for any of the following PacificSource Cascade Gold preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for PacificSource Cascade Gold?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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