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Portland State University
2022-2023 Domestic Student Health Insurance
Health Insurance Requirement and Eligibility
Domestic Students
• All registered domestic students taking five (5) or more PSU
institutional credits* during Fall, Winter and Spring/Summer terms
are automatically enrolled in the PSU-sponsored Student Health
Insurance Plan unless they choose to submit an approved online
insurance waiver of comparable coverage
• The cost per term is $1,108 for Fall, Winter and Spring/Summer
terms. All students who have the Spring term insurance will
automatically be covered through Summer term, for no added cost,
regardless of graduation, vacation term, or number of Summer credit
hours. The Summer Only rate is $794.
• The Student Health Insurance Plan can be used worldwide and
referrals or use of Center for Student Health and Counseling (SHAC)
are not required.
• If you are not enrolled in five or more credit hours by the Waiver
deadline, you will not be eligible for the PSU-sponsored Student
Health Insurance Plan.
*NOTE: Restricted Differential credits do not apply to the PSU health
insurance mandate. These types of credits are mostly study abroad and
some continuing education courses. For information:
pdx.edu/student-finance/tuition. Please check the footnotes of your class
descriptions or your student account to see whether or not you have been
charged.
Withdrawal From School
If you leave PSU for the reason of a covered accident or sickness resulting in
a medical leave of absence, you will be eligible for continued coverage under
this Plan for only one term during your PSU academic career. For information
to see if you qualify, please contact the SHAC Insurance Team at
Please make sure you understand your school’s credit hour and other
requirements for enrolling in this plan. PacificSource Health Plans reserves
the right to review, at any time, your eligibility to enroll in this plan. If it is
determined that you did not meet the school’s eligibility requirements for
enrollment, your participation in the plan may be terminated in accordance
with its terms and applicable law.
How much does it cost?
PREMIUM COSTS AND COVERAGE PERIODS
COVERAGE
PERIODS
FALL
09/20/22 –
01/08/23
WINTER
01/09/23 -
04/02/23
SPRING/
SUMMER
04/03/23 -
09/19/23
SUMMER
ONLY
06/26/23 -
09/19/23
Waiver
Deadline
10/09/22
01/22/23
04/16/23
07/09/23
Student only
$1,108
$1,108
$1,108
$794
Note: coverage is for domestic students only. Domestic dependents are not
covered.
Rates include a premium payable to Academic HealthPlans (AHP), as well as
administrative fees payable to PSU and AHP. Rates also include Academic
Emergency Services provided through 4 Ever Life International Limited and
administered by Worldwide Insurance Services, LLC, separate and independent
companies from Academic HealthPlans.
You can view the standard Summary of Benefits & Coverage (SBC) which is required by Health
Care Reform. It summarizes your coverage in a format that all insurance companies now use.
To view your plan SBC, go to: pacificsource.com/psu/
Learn More! pdx.edu/health-counseling
Where do I go for care?
Think SHAC First! At SHAC you can find high quality, accessible mental health,
physical health and dental services – all under one roof! We are committed to
creating and maintaining an environment where all people of diverse backgrounds
and identities can expect to be valued and treated with respect and dignity.
In addition to in-person appointments, SHAC offers telehealth and telemental
health services for PSU Students. Both are considered office visits and are covered
by the Student Health Fee.
Most services at SHAC are covered by a per term Student Health Center Fee
included in your student tuition (if taking 5 or more credit hours*). Should you
incur additional medical or mental health fees, SHAC will bill PacificSource on your
behalf and no deductible will be applied.
Questions? Contact SHAC:
Address: 1880 SW 6th Ave UCB 200 Portland, OR
Phone: 503.725.2800
Website: pdx.edu/health-counseling
Email: askshac@pdx.edu
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What does the plan offer?
This flyer is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general
description of plan benefits and programs and does not constitute a contract. Covered Medical Expenses are subject to plan maximums,
limitations, and exclusions as described in the Policy. The PPO network is Voyager.
Annual Deductible
Per visit or admission deductibles do not apply toward satisfying the
plan Deductible.
Your Annual Deductible is waived for all services rendered at SHAC.
The following Deductibles are applied before Covered
Medical Expenses are payable:
In-Network Provider: $300 per Insured per Policy Year
Out-of-Network Provider: $600 per Insured per Policy Year
Out of Pocket Maximums
Once the Individual Out-of-Pocket Limit has been satisfied, Covered Medical
Expenses will be payable at 100% for the remainder of the Policy Year, up to
any benefit maximum that may apply. Coinsurance, Deductibles, Copays and
Prescription Drug expenses apply to the Out-of- Pocket Limit. Services that do
not apply toward satisfying the Out-Of-Pocket Limit: expenses that are not
Covered Medical Expenses; expenses for Designated Care penalties, and
other expenses not covered by this Plan.
In-Network Provider: $8,700 per Insured per Policy Year
Out-of-Network Provider: $17,400 per Insured per Policy Year
BENEFIT
CATEGORY
IN-NETWORK PROVIDER
OUT-OF-NETWORK PROVIDER
Physician’s Office Visit Expense, Copay is due at time
of visit.
100% of the Negotiated Charge after a
$35 Copay per visit including Mental Health
50% of the Recognized Charge after a
$70 Copay per visit
Inpatient Hospitalization, Room and
Board Expense, Semi-private room
After a $250 Copay per admission,
70% of the Negotiated Charge
50% of the Recognized Charge
Emergency Room, Important Note: Please note that
as Non- participating Providers that do not have a
contract with Pacific- Source, the provider may not
accept payment of your cost share (your deductible
and Coinsurance) as payment in full. You may
receive a bill for the difference between the amount
billed by the provider and the amount paid by this
Plan.
70% of the Negotiated Charge after a
$250 Copay per visit
(Copay waived if admitted)
70% of the Recognized Charge after a
$250 Copay per visit
(Copay waived if admitted)
Urgent Care Expenses
100% of the Negotiated Charge after a
$50 Copay per visit
50% of the Recognized Charge after a
$60 Copay per visit
X-Ray and Lab
70% of the Negotiated Charge
50% of the Recognized Charge
Ambulance
After a $150 Copay per trip,
80% of the Negotiated Charge
After a $150 Copay per trip,
80% of the Recognized Charge
Surgical Expense
After a $150 Copay per surgery
70% of the Negotiated Charge
50% of the Recognized Charge
Anesthesia Expense
70% of the Negotiated Charge
70% of the Negotiated Charge
Ambulatory Surgical Expense
70% of the Negotiated Charge
50% of the Recognized Charge
Therapy Expense, For the following types of therapy
provided on an outpatient basis: Physical Therapy,
Chiropractic Care, Speech Therapy, or Occupational
Therapy.
70% of the Negotiated Charge after a
$35 Copay per visit
50% of the Recognized Charge after a
$70 Copay per visit
Mental and Nervous Disorders - Inpatient
70% of the Negotiated Charge after a
$100 Copay per admission
50% of the Recognized Charge
Mental and Nervous Disorders - Outpatient
100% of the Negotiated Charge after a
$35 Copay per visit
50% of the Recognized Charge
Prescription Drug Expense
30 Day Supply. Contraceptives (that do not
have a generic alternate) covered at 100%.
Please Note: You are required to pay in full at the
time of service for all Prescriptions dispensed at a
Non- Participating Pharmacy.
To learn more about your prescription benefits visit
pacificsource.com/psu/
Note: Specialty prescription drugs can only be
obtained through Caremark.
Please visit
PacificSource.com/members/prescription-drug-
information for more information about your
covered prescription & preventative drug options.
In-Network Provider Pharmacy:
(Deductible waived)
100% of the Negotiated Charge following a
$25 Copay for each Generic,
$50 Copay for each Preferred Brand Name,
$75 Copay for each Non-Preferred Brand Name, and
70% Coinsurance up to $250 for each Specialty Prescription Drug
Out-of-Network Provider Pharmacy:
(Deductible waived)
100% of the Recognized Charge following a
$25 Copay for each Generic,
$50 Copay for each Preferred Brand Name,
$75 Copay for each Non-Preferred Brand Name
70% Coinsurance up to $250 for each Specialty Prescription Drug
This material is for information only and is not an offer or invitation to contract. Health insurance plans contain exclusions, limitations, and benefit maximums. Providers are independent contractors and are not agents of PacificSource
or AHP. Provider participation may change without notice. PacificSource or AHP does not provide care or guarantee access to health services. Information is believed to be accurate as of the production date; however, it is subject to
change. Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or who
conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
