2019-2020
Portland State University
Domestic & International Student Health Insurance Plan
www.pdx.edu/shac
IMPORTANT CONTACTS
Benets and claims quesons:
PacicSource Health Plans
P.O. Box 7068
Springeld, OR 97475
(855) 274-9814 (toll-free)
hps://PacicSource.com/psu
Underwrien by:
PacicSource Health Plans
Policy #G0033730
To nd a doctor or
health care provider:
PacicSource Parcipang
Provider Network
(855) 274-9814 (toll-free)
hps://PacicSource.com/psu
Prescripons:
PacicSource
Pharmacy Management
(855) 274-9814
or direct to Pharmacy Services
(800) 624-6052, ext 3784
hps://PacicSource.com/psu
SHAC (Center for Student Health & Counseling):
(503) 725-2800
pdx.edu/shac
24-Hour Nurse Advice Line:
(844) 224-3145
24/7 Emergency Travel Assistance:
On Call Internaonal
One Delaware Drive
Salem, NH 03079
(866) 525-1956 (Toll-free within the U.S.)
(603) 328-1956 (Outside the U.S.)
www.oncallinternaonal.com
Eligibility, coverage, and
general quesons:
USI Student Insurance
(800) 853-5899
Mon - Fri, 8am-5pm PST
hps://studennsurance.usi.com
Plan brokered by:
USI Insurance Services, LLC
OR License No. 802263
The Portland State University student health insurance plan is underwrien by PacicSource Health Plans also referred to PacicSource.
You can view the standard Summary of Benets & 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: hps://pacicsource.com/psu.
•2• Portland State University
IMPORTANT NOTICE
This is just a brief descripon of your benets. For informaon regarding the full Student Guide (which includes plan benets, exclusions and limitaons, and
informaon about refund requests, how to le a claim, mandated benets and other important informaon) please call PacicSource at (855) 274-9814 or
send an email to StudentHealth@pacicsource.com. You will be able to obtain a copy of the full Student Guide as soon as it is available.
If any discrepancy exists between this Benet Summary and the Policy, the Student Guide will govern and control the payment of benets.
When Coverage Begins
Coverage under the Plan once premium has been collected will become ef-
fecve at 12:01 a.m. on the later of, but no sooner than:
• The Student Guide eecve date;
• The beginning date of the term for which premium has been paid;
• The day aer the Enrollment Form (if applicable) and premium payment
are received by USI Student Insurance, Authorized Agent or University;
or
• The day aer the date of postmark if the Enrollment Form is mailed.
IMPORTANT NOTICE - Premiums will not be pro-rated if the Insured enrolls
past the rst date of coverage for which he or she is applying. Final deci-
sions regarding coverage eecve dates are made by PacicSource Health
Plans.
The below enrollments will be allowed a 14 day grace period from the term
start date to enroll whereby the eecve date will be backdated a maximum
of 14 days. No policy shall ever start prior to the term start date:
• All hard-waiver and mandatory (insurance is required as a condion of
enrollment on campus) insurance programs.
• All re-enrollments into the same exact policy if re-enrollment occurs
within 31 days of the prior policy terminaon date.
When Coverage Ends
Insurance of all Insured Persons terminates at 11:59 p.m. on the earlier of:
• Date the Student Guide terminates for all Insured Persons; or
• End of the period of coverage for which premium has been paid; or
• The start of the term if the Insured Person ceases to be eligible for the
insurance; or
• Date the Insured Person enters military service.
• In the event there is overlapping coverage under the same Student
Guide number, the policy with the earliest eecve date will stay in force
through its terminaon date and the subsequent policy will go into ef-
fect immediately aerward with no gap in coverage.
COVERAGE IS NOT AUTOMATICALLY RENEWED. Eligible Persons must re-
enroll when coverage terminates to maintain coverage. NO nocaon of
plan expiraon or renewal will be sent.
Connued on next page
Health Insurance Requirement
and Eligibility
Domesc Students
All registered domesc students taking 5 or more in-load non-restricted dif-
ferenal
*
Portland State University ( PSU) credit hours o r more during Fall,
Winter and Spring/Summer combined terms are automacally enrolled in
the PSU-sponsored Student Health Insurance Plan unless they choose to sub-
mit an approved online insurance waiver of comparable coverage. Eligible
students will be charged a Health Insurance Fee of $890 for each of the fol-
lowing terms: Fall, Winter, Spring/Summer combined. Students only need
one approved waiver per academic year. All students who have the student
health insurance plan during Spring term 2020, will be covered until 11:59
pm on September 19, 2020, regardless of summer credit hours. This means
that if you have paid the Spring/Summer combined charge, you will have con-
nuous coverage throughout the Summer term, regardless of taking classes,
traveling, or graduating. Please check the website for updates on the sum-
mer insurance charges if Summer 2020 is the student’s first term at PSU:
www.pdx.edu/shac.
If you are not enrolled in ve or more in-load credit hours by the Waiver
Deadline, you will not be eligible for the PSU-sponsored Student Health In-
surance Plan.
*NOTE: Restricted Dierenal credits, including some connuing educaon,
most study abroad and TV/Video or Satellite classes are not eligible for the
Student Health Fee which gives access to the Center for Student Health &
Counseling (SHAC), and are also not eligible for this insurance plan. If you
have quesons about the types of credits you are taking, visit:
hp://www.pdx.edu//student-nancial/restricted-dierenal-tuion
Internaonal Students
Oregon law requires that all internaonal students at Portland State Universi-
ty (PSU) in F-1 and J-1 visa status have adequate medical insurance coverage.
It is the policy of PSU that these students purchase year-round health insur-
ance coverage through the University even during vacaon terms o r while
out of the country.
All Internaonal students taking 1 or more credit are automacally enrolled
in the PSU-sponsored Student Health Insurance Plan unless they are eligible
and choose to submit an approved online insurance waiver of comparable
coverage. International students will be charged a Health Insurance Fee of
$890 for each of the following terms: Fall, Winter, Spring/Summer Combined.
All students who have the student health insurance plan during Spring term
2020, will be covered until 11:59 pm on September 19, 2020 regardless of
summer credit hours. This means that if you have paid the Spring/Summer
combined charge, you will have connuous coverage throughout the Sum-
mer term, regardless of taking classes, traveling, or graduang.
Internaonal students arriving a few weeks early or staying a few weeks aer
a term, and those on Oponal Praccal Training (OPT), need to enroll direct-
ly with USI Student Insurance by calling (800) 853-5899 and pay for weekly
health insurance with a credit card.
Please make sure you understand your school’s credit hour and other require-
ments for enrolling in this plan. PacicSource Health Plans reserves the right
to review, at any me, your eligibility to enroll in this plan. If it is determined
that you did not meet the school’s eligibility requirements for enrollment,
your parcipaon in the plan may be terminated or rescinded in accordance
with its terms and applicable law.
•3• Portland State University
Eligibility Requirement
You must meet the Eligibility requirements each me you pay a premium to
connue insurance coverage. It is the student’s responsibility to make mely
renewal payment to avoid a lapse in coverage.
Eligible students who involuntarily lose coverage under another group insur-
ance plan are also eligible to purchase the Portland State University Student
Health Insurance Plan. These students must provide the PSU Student Health
Insurance Coordinator, located at SHAC, with proof that they have lost insur-
ance through another group (cercate and leer of ineligibility) within 31
days of the qualifying event. The eecve date would be the later of: a) term
eecve date, or b) the day aer prior coverage ends if enrollment request
is received by the PSU Health Insurance Coordinator within 30 days from loss
of prior coverage.
To be an Insured under the Policy, the student must have paid the required
premium and his/her name, student number and date of birth must have
been included in the declaraon made by the School or the Administrave
Agent to the Insurer. All students must acvely aend classes for the rst 14
consecuve days following their eecve date for the term purchased, and/
or pursuant to their visa requirements for the period for which coverage is
purchased, except during school authorized breaks or in case of a medical
withdrawal, approved by your school and any applicable regulatory authority.
Please contact your school or USI Student Insurance for details.
Dependent Coverage
Domesc Students
No dependent coverage is oered to domesc students under this plan.
Internaonal Students
Dependent enrollment in this plan is voluntary. Eligible Internaonal Insured
Students, may purchase Dependent coverage at the me of student’s enroll-
ment in the plan; or within 31 days of one of the following qualied events:
marriage, addion of domesc partner, birth, or adopon. Eligible depen-
dents are the spouse or legally registered and valid domesc partner which
resides with the Insured Student, and the student’s, the spouse’s, or the do-
mesc partner’s natural child, stepchild, or legally adopted child under 26
years of age. No coverage is oered to Newborns if the dependent is not
enrolled in this plan.
Health Insurance Requirement
and Eligibility
Dependents must be enrolled for the same term of coverage for which the
Insured Student enrolls. Dependent coverage expires concurrently with that
of the Insured Student and Dependents must re-enroll when coverage termi-
nates to maintain coverage.
Dependents must be re-enrolled each term. It is the students responsibility
to contact USI Student Insurance prior to the enrollment deadline listed in
this brochure. No reminder will be sent to students or dependents covered
under the plan.
To enroll your dependent(s) you must call USI Student Insurance Customer
Care Unit at (800) 853-5899.
Withdrawal From School
If you leave Portland State University for reason of a covered accident or sick-
ness resulng in a University approved Medical Leave of Absence, you will be
eligible for connued coverage under this Plan for only the rst term imme-
diately following your leave, provided you have approval by your school and
any applicable regulatory authority, and you were enrolled in this Plan for the
Fall, Winter and/or Spring/Summer term previous to your leave. Please note
enrollment in the Summer only term does not entle you to medical leave
of absence coverage for the Fall term. Enrollment must be iniated by the
student and is not automac. All applicable enrollment deadline dates apply.
You must pay the applicable insurance premium. A maximum of one term of
medical leave will be granted by Portland State University during your aca-
demic career. Contact [email protected] for more informaon.
Insurance Waiver Information
If you have insurance that is comparable
*
to the PSU Student Health Insur-
ance Plan oered through a dierent insurance company (i.e. through an em-
ployer, spouse, parent/guardian, scholarship, etc.), and DO NOT want to take
part in this PSU Plan, you must complete the online waiver process by the
Waiver Deadline or your student account will be charged. Students only need
one approved waiver per academic year (9/20/19 - 9/19/20).
If you do not have insurance no acon is required. You will automacally be
enrolled in the PSU PacicSource Student Policy each term you are eligible,
(Fall, Winter, Spring/Summer combinaon), and your student account will be
charged.
*
Comparable coverage requires no more than a $2,500 deducble, access to
primary care services in the state of Oregon, and at least 70% inpaent hos-
pitalizaon coverage. To waive out of the insurance plan you must complete
the online waiver by the waiver deadline at www.pdx.edu/shac. For more
informaon visit www.pdx.edu/shac/insurance.
INTERNATIONAL STUDENT & DEPENDENT PLAN COST
TERM
FALL
9/20/19 - 1/5/20
WINTER
1/6/20 - 3/29/20
SPRING/SUMMER
3/30/20 - 9/19/20
SUMMER ONLY
6/21/20 - 9/19/20
Waiver Deadline 10/13/19 1/19/20 4/12/20 7/5/20
Student $890.00 $890.00 $890.00 $659.00
NOTE: Costs below are in addion to the student premium.
Dependents must be enrolled for the same term of coverage as student. Dependent enrollment in this plan is voluntary.
Dependent Enrollment Deadline 10/13/19 1/19/20 4/12/20 7/5/20
Spouse $890.00 $890.00 $890.00 $659.00
Per Child $890.00 $890.00 $890.00 $659.00
Rates include premium payable to PacicSource Health Plans, as well as administrave fees payable to PSU and USI Student Insurance. Rates also include Medical Evacuaon and
Repatriaon and Worldwide Emergency Travel Assistance benets/services provided through On Call Internaonal and its contracted underwring companies.
DOMESTIC STUDENT PLAN COST
TERM
FALL
9/20/19 - 1/5/20
WINTER
1/6/20 - 3/29/20
SPRING/SUMMER
3/30/20 - 9/19/20
SUMMER ONLY
6/21/20 - 9/19/20
Waiver Deadline 10/13/19 1/19/20 4/12/20 7/5/20
Student $890.00 $890.00 $890.00 $659.00
Note: coverage is for domestic students only. Domestic dependents are not covered.
•4• Portland State University
Premium Refund/Cancellation
A refund of premium will be granted for the reasons listed below only. No
other refunds will be granted.
1. All hard-waiver and mandatory (insurance is required as a condion of
enroll ment on campus) enrollments will NOT receive a refund of your
insurance premium aer the Waiver Deadline of the term has passed.
For direct enrollments with USI Student Insurance that are paid using a
credit card or check (not charged to your PSU student account): if you
withdraw from school within the rst 14 days of the coverage period,
you will receive a full refund of the insurance premium provided that
you did not le a medical claim during this period. Wrien proof of
withdrawal from the school must be provided. If you withdraw aer 14
days of the coverage period, your coverage will remain in eect unl the
end of the term for which you have paid the premium. Refund requests
for these enrollments should be directed to USI Student Insurance at
(800) 853-5899 or via email at studen[email protected].
2. If you or your insured dependents enter the armed forces of any country
you and your insured dependents will not be covered under the Master
Policy as of the date of such entry. If you enter the armed forces the
policy will be cancelled as of the date of such entry. If your dependent
enters the armed forces, a pro-rata refund of premium will be made for
such person, upon wrien request received by USI Student Insurance
within 31 days of entry into service.
3. Refunds will be granted for insured dependents in case of a qualifying
event such as legal separaon, divorce or death within 31 days of the
occurred event, provided that your insured dependents did not le a
medical claim during the insured period. Wrien proof of such qualify-
ing event must be submied. Refunds will not be prorated.
INSURANCE PAYMENTS WITH PERSONAL CHECK
For direct enrollments with USI Student Insurance that are not charged to
your PSU student account: If you make your insurance payment via personal
check payable to USI Student Insurance and we are unable to process the
check (due to insucient funds, closure of account, etc.), your and your de-
pendents’ insurance coverage will be terminated retroacve to the eecve
date of the enrolled term.
Where Do I Go For Care?
When you need care, consider the PSU Center for Student Health & Coun-
seling (SHAC) on campus as your rst stop. SHAC can provide many of the
roune health services you need. Most services at SHAC are covered by a per
term Student Health Fee included in your student tuion (for those taking 5
or more non-Restricted Dierenal credit hours). Should you incur addional
medical or counseling fees, SHAC will bill PacicSource on your behalf and no
deducble will be applied.
SHAC provides high-quality, accessible, medical, counseling and dental ser-
vices to PSU students. SHAC has an incredible sta of licensed health care
professionals who are all dedicated to keeping students healthy so they can
stay in the classroom and focus on learning.
Located at 1880 SW 6th Avenue, Suite 200, University Center Building
(503) 725-2800 • www.pdx.edu/shac
You may visit any licensed health care provider directly for covered services,
however, when you select a Preferred Provider, you will generally have less
out of pocket expense for your care. Referrals from SHAC are not required for
covered services received outside of SHAC. For more informaon, visit:
hps://pacicsource.com/psu.
ID Cards
Medical ID cards may be shipped before or shortly aer of your policy eec-
ve date. Providers need the ID number shown on your ID card to idenfy
you, verify your coverage and bill PacicSource. You do not need an ID card to
be eligible to receive benets; if you need medical aenon before receiving
your ID card, benets will be payable according to the Policy. Once you have
received your ID card, present it to the provider to facilitate prompt payment
of your claim. You can also print your ID cards at:
hps://PacicSource.com/psu or access an ID card on your mobile device.
•5• Portland State University
Participating Provider Network
PacicSource has arranged for you to access the PacicSource parcipang
network. It is to your advantage to ulize a Parcipang Provider because sav-
ings can be achieved from the Contracted Allowable Fee these providers have
agreed to accept as payment for their services. Students are responsible for
informing their providers of potenal out-of-pocket expenses for a referral to
both a Parcipang Provider and a Non-Parcipang Provider. Parcipang
Providers are independent contractors and are neither employees nor agents
of either University or PacicSource. To nd a Parcipang Provider, you can
use PacicSource’s online provider directory located at:
hps://PacicSource.com/psu.
Prescription Drug Claim Procedure
When obtaining a covered prescripon, please present your ID card to a Par-
cipang Pharmacy, along with your applicable Co-payment. The pharmacy
will bill PacicSource for the cost of the drug, plus a dispensing fee, less the
Co-payment amount.
When you need to ll a prescripon, and do not have your ID card with you,
you may obtain your prescripon from a Parcipang Pharmacy, and be reim-
bursed by subming a completed Prescripon Drug claim form. You will be
reimbursed for covered medicaons, less your Co-payment. For a prescrip-
on claim form, go to hps://PacicSource.com/psu.
Prescripons from a Non-Parcipang Pharmacy must be paid for in full at
the me of service and submied for reimbursement.
Member Web: InTouch for Members
Got Quesons? Get Answers with InTouch
As a PacicSource insurance member, you have access to InTouch, your se-
cure member website, with access to your insurance informaon and a
wealth of health and wellness resources. You can take full advantage of the
interacve website to complete a variety of self-service transacons online
24 hours a day. You can also stay “InTouch” no maer where you are with the
free Mobile App available both on iPhone® and Android™ at:
hps://Pacicsource.com/PSU
By logging into InTouch, you can:
• Look up coverage informaon and review benet summaries
• Check the status of a claim and access your claim history
• View Explanaon of Benets (EOB) statements for paid claims
• Order new and print temporary ID cards
• Access health and wellness resources
• Find a provider, hospital, or urgent care center
How do I register?
• Go to hps://PacicSource.com/psu
• Have your PacicSource Member ID card handy
• Click on the Register Now link on the right side of your screen
• Follow the onscreen instrucons
Need help with registering onto InTouch?
Technical assistance is available toll free, Monday through Friday at (855)
274-9814. Hours are 7am - 5 pm PST.
Coordination of Benets
If the Enrollee is insured under more than one group health plan, the benets
of this Plan, that covers the insured student, will be used before those of a
plan that provides coverage as a dependent. When both parents have group
health plans that provide coverage as a dependent, the benets of the plan
of the parent whose birth date falls earlier in the year will be used rst. The
benets available under this Plan may be coordinated with other benets
available to the Enrollee under any auto insurance, Workers’ Compensaon,
Medicare, or other coverage. This Plan pays in accordance with the rules set
forth in the Policy.
Extension of Benets
If an Enrollee is conned to a hospital on the date his or her insurance ter-
minates, expenses incurred aer the terminaon date and during the con-
nuance of that hospital connement, shall be payable in accordance with
the Plan unl the Enrollee is released or benets are exhausted, whichever
occurs rst.
How Do I File a Claim?
Your Parcipang Provider will le claims with PacicSource. All you need to
do is show your ID card to the Parcipang Provider.
If you receive care from a Non-Parcipang Provider, the provider may sub-
mit the claim to PacicSource for you. If not, you are responsible for sending
the claim to PacicSource for processing. Your claim must include a copy of
your provider’s itemized bill. It must also include your name, ID number or/
and the paent’s name. If you were treated for an accidental injury, please
include the date, me, place, and circumstances of the accident.
All claims for benets should be turned in to PacicSource within 90 days of
the date of service. If it is not possible to submit a claim within 90 days, turn
in the claim with an explanaon as soon as possible. In some cases Pacic-
Source may accept the late claim. We will never pay a claim that was submit-
ted more than a year aer the date of service.
PacicSource has the sole right to pay benets to the Enrollee, the provider,
or both jointly. You will receive an “Explanaon of Benets” when your claims
are processed. The Explanaon of Benets will explain how your claim was
processed, according to the benets of your Student Health Insurance Plan.
All claims should be sent to:
PacicSource Health Plans
An: Claims Department
P.O. Box 7068, Springeld, OR 97475-0068
(541) 225-2741 or (855) 274-9814 (toll-free)
Customer Service Representaves are available 7:00 a.m. to 5:00 p.m. (PST),
Monday through Friday, for any quesons. Claim forms can be obtained by
calling the number above or by vising hps://PacicSource.com/psu.
How to Appeal a Claim
In the event an Enrollee disagrees with how a claim was processed, he or
she may request a review of the decision. The Enrollee’s requests must be
made in wring within 180 days of the date of the Explanaon of Benets
(EOB). The Enrollee’s request must include why he or she disagrees with the
way the claim was processed. The request must also include any addional
informaon that supports the claim (e.g., medical records, physician’s oce
notes, operave reports, physician’s leer of medical necessity, etc.). Please
submit all requests to:
PacicSource Health Plans
An: Appeals
P.O. Box 7068, Springeld, OR 97475-0068
Notice
PacicSource has strict policies in place to protect the condenality of your
personal informaon, including your medical records. Your personal infor-
maon is only available to the PacicSource sta members who need that
informaon to do their jobs.
Disclosure outside PacicSource is allowed only when necessary to provide
your coverage, or when otherwise allowed by law. Except when certain stat-
utory excepons apply, state law requires us to have wrien authorizaon
from you (or your representave) before disclosing your personal informa-
on outside PacicSource. An example of one excepon is that we do not
need wrien authorizaon to disclose informaon to a designee performing
ulizaon management, quality assurance, or peer review on our behalf.
To obtain a copy of our noce describing in greater detail our pracces con-
cerning use and disclosure of personal informaon, please call the toll-free
Customer Services number on your ID card or visit PacicSource on the inter-
net at: hps://PacicSource.com/psu.
•6• Portland State University
Deductibles & Maximums
Annual Benet Maximum Unlimited
Annual Deducbles - Per visit or admission deducbles do not apply to-
wards sasfying the plan Deducble. Your Annual Deducble is waived
for all services rendered at SHAC.
The following Deducbles are applied before Covered Medical Expenses are
payable:
Preferred Care: $300 per Insured per Policy Year
Non-Preferred Care: $600 per Insured per Policy Year
Coinsurance
Covered Medical Expenses are payable at the coinsurance percentage specied
below, aer any applicable deducble, up to an unlimited maximum benet.
Annual Out of Pocket Maximums
- Once the Individual Out-of-Pocket Limit has
been sased, Covered Medical Expenses will be payable at 100% for the remainder
of the Policy Year, up to any benet maximum that may apply. Coinsurance, Deduct-
ibles, Co-pays and Prescripon Drug expenses apply to the Out-of-Pocket Limit. Ser-
vices that do not apply towards sasfying the Out-Of-Pocket Limit: expenses that are
not Covered Medical Expenses; expenses for Designated Care penales,and other
expenses not covered by this Plan.
Preferred Care: $5,000 per Insured per Policy Year
Non-Preferred Care: $10,000 per Insured per Policy Year
Connued on next page
The Plan will pay benets in accordance with any applicable Oregon State Insurance Law(s).
NOTE: Deducbles, coinsurance and copays are waived when services are rendered at SHAC.
Waiver of Annual Deductible
In compliance with Federal Health Care Reform legislaon, the Annual Deducble is waived for Preferred Care Covered Medical Expenses rendered as part of
the following benet types: Roune Physical Exam Expense (Oce Visits), Pap Smear Screening Expense, Mammogram Expense, Roune Screening for Sexu-
ally Transmied Disease Expense, Roune Colorectal Cancer Screening, Roune Prostate Cancer Screening Expense, Prevenve Care Immunizaons (Facility or
Oce Visits), Well Woman Prevenve Visits (Oce Visits), Screening & Counseling Services (Oce Visits) as illustrated under the Roune Physical Exam benet
type, Roune Cancer Screenings (Outpaent), Prenatal Care (Oce Visits), Comprehensive Lactaon Support and Counseling Services (Facility or Oce Visits),
Breast Pumps & Supplies, Family Contracepve Counseling Services (Oce Visits), Female Voluntary Sterilizaon (Inpaent and Outpaent), Pediatric Preven-
ve Vision and Dental Service, Female Contracepves Generic Prescripon Drugs, Brand Prescripon Drugs if no Generic equivalent. FDA-Approved Female
Generic Emergency Contracepves. In compliance with Oregon State Mandate(s) the Policy Year Deducble is also waived for: Maternal Diabec Services from
concepon to 6 weeks post-partum. Your Annual deducble will also be waived for all services rendered at SHAC.
Schedule of Benets
IMPORTANT NOTICE
This is just a brief descripon of your benets. For informaon regarding the full Student Guide (which includes plan benets, exclusions and limitaons, and informaon
about refund requests, how to le a claim, mandated benets and other important informaon) please call PacicSource at (855) 274-9814 or send an email to
StudentHealth@pacicsource.com. You will be able to obtain a copy of the full Student Guide as soon as it is available. If any discrepancy exists between this
Benet Summary and the Policy, the Student Guide will govern and control the payment of benets.
Inpatient Hospitalization Services
Preferred Care Non-Preferred Care
Room and Board Expense, Semi-private room.
Aer a $250 Co-pay
per admission,
80% of the Negoated Charge
50% of the Recognized Charge
Intensive Care Room and Board Expense
Aer a $250 Co-pay
per admission,
80% of the Negoated Charge
50% of the Recognized Charge
Non-Surgical Physicians, Charges for the non-surgical services of the aending
Physician, or a consulng Physician.
80% of the Negoated Charge 50% of the Recognized Charge
Miscellaneous Hospital Expense, Includes; among others; expenses incurred during a
hospital connement for: anesthesia and operang room; laboratory tests and x rays;
oxygen tent; and drugs; medicines; and dressings.
80% of the Negoated Charge 80% of the Recognized Charge
Surgical Expense (Inpatient & Outpatient)
Preferred Care Non-Preferred Care
Surgical Expense
Aer a $100 Co-pay per surgery,
80% of the Negoated Charge
50% of the Recognized Charge
Anesthesia Expense 80% of the Negoated Charge 80% of the Recognized Charge
Ambulatory Surgical Expense 80% of the Negoated Charge 50% of the Recognized Charge
Ambulatory Surgical Center
Aer a $100 Co-pay,
80% of the Negoated Charge
50% of the Recognized Charge
Connued on next page
•7• Portland State University
Schedule of Benets (continued)
Outpatient Benets
Preferred Care Non-Preferred Care
Physician’s Oce Visit Expense. Co-pay is due at me of visit and is in addion to the plan
deducble.
100% of the Negoated Charge
aer a $25 Co-pay per visit
50% of the Recognized Charge
aer a $40 Co-pay per visit
Preventave Care Services, Including but not limited to roune physical exams,
immunizaons and diagnosc X-ray & lab for roune physical exams.
100% of the Negoated Charge 50% of the Recognized Charge
Laboratory and X-Ray Expense 80% of the Negoated Charge 50% of the Recognized Charge
Emergency Room Visit Expense. Important Note: Please note that as Non-parcipang
Providers do not have a contract with PacicSource, the provider may not accept
payment of your cost share (your deducble and co-insurance) as payment in full. You
may receive a bill for the dierence between the amount billed by the provider and the
amount paid by this Plan. The co-pay is in addion to the plan deducble.
80% of the Negoated Charge
aer $250 Co-pay per visit
(Co-pay waived if admied)
80% of the Recognized Charge
aer $250 Copay per visit
(Co-pay waived if admied)
Urgent Care Expense. Please note: A covered person should not seek medical care
or treatment from an urgent care provider if their illness, injury, or condion, is an
emergency condion. The covered person should go directly to the emergency room of
a hospital or call 911 for ambulance and medical assistance. The Co-pay is in addion to
the plan deducble.
100% of the Negoated Charge
aer a $30 Co-pay per visit
50% of the Recognized Charge
aer a $50 Co-pay per visit
Advanced Diagnosc Imaging (ie MRI, CT, PET) Expense
80% of the Negoated Charge
aer $100 Co-pay
50% of the Recognized Charge
Ambulance Expense
80% of the Negoated Charge
aer $100 Co-pay per trip
80% of the Recognized Charge
aer $100 Co-pay per trip
Therapy Expense, For the following types of therapy provided on an outpaent basis:
Physical Therapy, Chiropracc Care, Speech Therapy, or Occupaonal Therapy.
80% of the Negoated Charge
aer a $25 Co-pay per visit
50% of the Recognized Charge
aer a $40 Co-pay per visit
Durable Medical Equipment Expense 80% of the Negoated Charge 50% of the Recognized Charge
Diagnosc Tesng for Learning Disabilies Expense 80% of the Negoated Charge 50% of the Recognized Charge
Treatment for Learning Disabilies Expense
100% of the Negoated Charge
aer a $25 Co-pay per visit
50% of the Recognized Charge
Allergy Tesng and Treatment Expense, Includes laboratory tests, physician oce visits
to administer injecons, prescribed medicaons for tesng and treatment of the allergy,
and other medically necessary supplies and services.
80% of the Negoated Charge 50% of the Recognized Charge
Impacted Wisdom Teeth Expense
80% of the Actual Charge
100% of the Actual Charge
when performed at SHAC
80% of the Actual Charge
Dental Injury Expense
80% of the Actual Charge
100% of the Actual Charge
when performed at SHAC
80% of the Actual Charge
Diabec Tesng Supplies Expense, Including test strips, diabec test agents, glucose
tablets, lancets/lancing devices, and alcohol swabs and blood glucose monitors.
80% of the Negoated Charge 50% of the Recognized Charge
Mental Health Benets
Preferred Care Non-Preferred Care
Inpaent Expense, Charges incurred while conned as a full-me inpaent in a hospital
or residenal treatment facility for the treatment of mental and nervous disorders. Prior
review and approval must be obtained from PacicSource.
80% of the Negoated Charge
aer $100 Co-pay per admission
50% of the Recognized Charge
Outpaent Expense, Charges for marriage and family therapies are not covered.
100% of the Negoated Charge
aer a $25 Co-pay per visit
50% of the Recognized charge
Alcoholism and Drug Addiction Treatment
Preferred Care Non-Preferred Care
Inpaent Expense, For the treatment of alcohol and drug addicon.
80% of the Negoated Charge
aer a $100 Co-pay
per admission
50% of the Recognized Charge
Outpaent Expense, For the treatment of alcohol and drug addicon.
100% of the Negoated Charge
aer a $25 Co-pay per visit
50% of the Recognized Charge
Maternity Benets
Preferred Care Non-Preferred Care
Maternity Expense, For the care of the covered person. 80% of the Negoated Charge 50% of the Recognized Charge
Well Newborn Nursery Care Expense, For the roune care of a covered newborn child.
See page 10 for addional informaon on this benet.
80% of the Negoated Charge 50% of the Recognized Charge
Connued on next page
•8• Portland State University
Additional Benets
Preferred Care Non-Preferred Care
Pap Smear Screening Expense 100% of the Negoated Charge 50% of the Recognized Charge
Mammogram Expense 100% of the Negoated Charge 50% of the Recognized Charge
Family Planning Expense, Includes charges incurred for services and supplies that are
provided to prevent pregnancy. See page 9 for addional informaon on this benet.
100% of the Negoated Charge 50% of the Recognized Charge
Roune Screening Expense, Includes charges for Chlamydia, Sexually Transmied
Disease (STD), Prostate, and Colorectal Cancer screenings.
100% of the Negoated Charge 50% of the Recognized Charge
Rehabilitaon Facility Expense 80% of the Negoated Charge 50% of the Recognized Charge
Human Organ Transplant Expense 80% of the Negoated Charge 50% of the Recognized Charge
Elecve Aboron Expense, Limited to a maximum of $2,500 per Policy Year 80% of the Negoated Charge 50% of the Recognized Charge
Transgender Surgery Expense, No dollar max. Covered to medical necessity. 80% of the Negoated Charge 50% of the Recognized Charge
Acupuncture Expense
80% of the Negoated Charge
aer $30 Co-pay per visit
50% of the Recognized Charge
Schedule of Benets (continued)
Prescription Medications
Preferred Care & Non-Preferred Care Pharmacy
Prescripon Drug Expense
30 Day Supply. Contracepves (that do not have a generic alternate) covered at 100%.
Please Note: You are required to pay in full at the me of service for all Prescripons
dispensed at a Non-Parcipang Pharmacy.
To learn more about your prescripon benets visit hps://PacicSource.com/PSU
Preferred Care Pharmacy:
100% of the Negoated Charge following a
$25 Co-pay for each Generic,
$50 Co-pay for each Preferred Brand Name,
$75 Co-pay for each Non-Preferred Brand Name, and
20% Coinsurance up to $250 for each Specialty Prescripon Drug
Non-Preferred Care Pharmacy:
100% of the Recognized Charge following a
$25 Co-pay for each Generic,
$50 Co-pay for each Preferred Brand Name,
$75 Co-pay for each Non-Preferred Brand Name, and
20% Coinsurance up to $250 for each Specialty Prescripon Drug
Mail Order Pharmacy Service
PacicSource partners with CVS Caremark for mail order services. Order up to a 90-
day supply of covered medicaons and have them delivered to you, with no standard
shipping charge. Visit:
hps://pacicsource.com/member/mail-order-rx.aspx to learn more and get started.
100% of the Negoated Charge following a $50 Co-pay for each
Generic,
$100 Co-pay for each Preferred Brand Name or $150 Co-pay for
each Non-Preferred Brand Name Prescripon Drug.
For more details about these benets, please see the Benet Descripons secon on the following pages.
•9• Portland State University
Benet Descriptions
Connued on next page
Prevenve Care Services: Benets include expenses for a roune physical
exam performed by a physician, physician assistant, or nurse praconer. If
charges for a roune physical exam given to a child who is a covered depen-
dent are covered under any other benet secon, those charges will not be
covered under this secon.
A roune physical exam is a medical exam given by a physician, physician as-
sistant, or nurse praconer, for a reason other than to diagnose or treat a
suspected or idened injury or sickness. Included as a part of the exam are:
• Roune vision and hearing screenings given as part of the roune physi-
cal exam.
• X-rays, lab, and other tests given in connecon with the exam, and
• Materials for the administraon of immunizaons for infecous disease
and tesng for tuberculosis.
In addion to any state regulaons or guidelines regarding mandated Roune
Physical Exam services, Covered Medical Expenses include services rendered
in conjuncon with,
• Screening and counseling services, such as:
- Interpersonal and domesc violence;
- Sexually Transmied Diseases; and
- Human Immune Deciency Virus (HIV) infecons.
• Screening for gestaonal diabetes.
• X-rays, lab and other tests given in connecon with the exam.
• Immunizaons for infecous diseases and the materials for administra-
on of immunizaons that have been recommended by the Advisory
Commiee on Immunizaon Pracces of the Centers for Disease Control
and Prevenon.
• If the plan includes dependent coverage, for covered newborns, an ini-
al hospital check up.
Any plan deducble, co-payment, and/or co-insurance amounts stated in
your Medical Benet Summary are waived for the following recommended
prevenve care services when provided by a parcipang provider:
• Services that have a rang of ‘A’ or ‘B’ from the U.S. Prevenve Services
Task Force (USPSTF);
• Immunizaons recommended by the Advisory Commiee on Immuniza-
on Pracces of the Centers for Disease Control and Prevenon (CDC);
• Prevenve care and screening for infants, children, and adolescents sup-
ported by the Health Resources and Services Administraon (HRSA);
• Prevenve care and screening for women supported by the HRSA that
are not included in the USPSTF recommendaons.
A and B list for prevenve services can be found at:
www.usprevenveservicestaskforce.org/Page/Name/
usps-a-and-b-recommendaons
The list of Women’s prevenve services can be found at:
www.hrsa.gov/womensguidelines
Important Note:
For details on the frequency and age limits that apply to Roune Physical Exams
and Roune Cancer Screenings, a covered person may contact his or her physi-
cian, by logging onto InTouch for Members: hps://PacicSource.com/psu or
calling the toll-free number on the back of the ID card.
Screening and Counseling Services: Covered Medical Expenses include charg-
es made by a physician in an individual or group seng for the following:
Obesity: Screening and counseling services to aid in weight reducon due to
obesity. Coverage includes:
• Prevenve counseling visits and/or risk factor reducon intervenon;
• Medical nutrion therapy;
• Nutrional counseling; and
• Healthy diet counseling visits provided in connecon with Hyperlipid-
emia (high cholesterol) and other known risk factors for cardiovascular
and diet-related chronic disease.
• Services in this category are subject to a combined limit of 26 individual
or group visits by any recognized provider per Policy Year. with excepon
to Dietary and Nutrional counseling for eang disorders (ie Bulimia and
Anorexia), that have no visitaon limit.
Misuse of Alcohol and/or Drugs: Screening and counseling services to aid in
the prevenon or reducon of the use of an alcohol agent or controlled sub-
stance. Coverage includes prevenve counseling visits, risk factor reducon
intervenon and a structured assessment.
• Use of Tobacco Products:
• Tobacco cessaon program services are covered at no charge only when
provided by a PacicSource approved program. Specic nicone re-
placement therapy will be covered according to the program’s descrip-
on. Tobacco cessaon related medicaon will be covered to the same
extent this policy covers other prescripon medicaons. Note: Oce
visits for tobacco cessaon do not have a visit limit.
• Tobacco product means a substance containing tobacco or nicone in-
cluding:
- cigarees;
- cigars;
- smoking tobacco;
- chewing tobacco;
- snu;
- smokeless tobacco; and
- candy-like products that contain tobacco.
Limitaons: Unless specied above, not covered under this Screening and
Counseling Services benet are charges incurred for:
• Services which are covered to any extent under any other part of this
Plan
Family Planning Expense: For females with reproducve capacity, Covered
Medical Expenses include those charges incurred for services and supplies
that are provided to prevent pregnancy. All services and supplies covered
under this benet must be approved by the Food and Drug Administraon
(FDA).
Coverage includes counseling services on contracepve methods provided by
a physician, obstetrician or gynecologist. Such counseling services are Cov-
ered Medical Expenses when provided in either a group or individual seng.
The following contracepve methods are covered expenses under this ben-
et:
Voluntary Sterilizaon: Covered expenses include charges billed separately
by the provider for female voluntary sterilizaon procedures and related ser-
vices and supplies including, but not limited to, tubal ligaon and sterilizaon
implants. Covered expenses under this Prevenve Care benet would not in-
clude charges for a voluntary sterilizaon procedure to the extent that the
procedure was not billed separately by the provider or because it was not the
primary purpose of a connement.
Limitaons:
Unless specied above, not covered under this benet are charges for:
• Services which are covered to any extent under any other part of this
Plan;
• Services which are for the treatment of an idened illness or injury;
• Services that are not given by a physician or under his or her direcon;
• Psychiatric, psychological, personality or emoonal tesng or exams;
• Any contracepve methods that are only “reviewed” by the FDA and not
“approved” by the FDA;
• Male contracepve methods or devices;
• The reversal of voluntary sterilizaon procedures, including any related
follow-up care.
Important note: Brand-Name Prescripon Drug or Devices will be covered
at 100% of the Negoated Charge, including waiver of Annual Deducble if a
Generic Prescripon Drug or Device is not available in the same therapeuc
drug class or the prescriber species Dispense as Wrien.
Therapy Expense: Covered Medical Expenses include charges incurred by a
covered person for the following types of therapy provided on an outpaent
basis:
• Physical Therapy,
• Chiropracc Care,
• Speech Therapy,
• Inhalaon Therapy,
•10• Portland State University
• Cardiac Rehabilitaon, or
• Occupaonal Therapy.
Expenses for Chiropracc Care are Covered Medical Expenses, if such care is
related to neuromusculoskeletal condions and condions arising from: the
lack of normal nerve, muscle, and/or joint funcon.
Services for speech therapy will only be allowed when needed to correct stut-
tering, hearing loss, peripheral speech mechanism problems, and decits due
to neurological disease or injury. Speech and/or cognive therapy for acute
illnesses and injuries are covered up to one year post injury when the ser-
vices do not duplicate those provided by other eligible providers, including
occupaonal therapists or neuropsychologists. This exclusion does not apply
if medically necessary as part of a treatment plan.
Covered Medical Expenses for chemotherapy, including an-nausea drugs
used in conjuncon with the chemotherapy, radiaon therapy, tests and pro-
cedures, physiotherapy (for rehabilitaon only aer a surgery), and expenses
incurred at a radiological facility. Covered Medical Expenses also include ex-
penses for the administraon of chemotherapy and visits by a health care
professional to administer the chemotherapy.
Benets for these types of therapies are payable for Covered Medical Expens-
es, on the same basis as any other sickness.
Allergy Tesng and Treatment Expense: Benets include charges incurred for
diagnosc tesng and treatment of allergies and immunology services.
Covered Medical Expenses include, but are not limited to, charges for the
following:
• laboratory tests,
• physician oce visits, including visits to administer injecons, pre-
scribed medicaons for tesng and treatment of the allergy, including
any equipment used in the administraon of prescribed medicaon, and
• other medically necessary supplies and services.
Maternity Expense: Covered Medical Expenses include inpaent care of the
covered person for a minimum of 48 hours aer a vaginal delivery and for a
minimum of 96 hours aer a cesarean delivery.
Any decision to shorten such minimum coverage shall be made by the at-
tending Physician, in consultaon with the mother. In such cases, Covered
Medical Expenses may include home visits, parent educaon, and assistance
and training in breast or bole-feeding.
Prenatal diagnosis of genec disorders of the fetus by means of diagnosc
procedures of a high-risk pregnancy, Maternity Expenses, and Complicaons
of Pregnancy are payable on the same basis as any other Sickness.
Benet Descriptions
Prenatal Care: Prenatal care will be covered for services received by a preg-
nant female in a physician’s, obstetrician’s, or gynecologist’s oce but only
to the extent described below. Coverage for prenatal care under this benet
is limited to pregnancy-related physician oce visits including the inial and
subsequent history and physical exams of the pregnant woman (maternal
weight, blood pressure and fetal heart rate check).
Comprehensive Lactaon Support and Counseling Services: Covered Medi-
cal Expenses will include comprehensive lactaon support (assistance and
training in breast feeding) and counseling services provided to females during
pregnancy and in the post-partum period by a cered lactaon support pro-
vider. The “post- partum period” means the 60 day period directly following
the child’s date of birth. Covered expenses incurred during the post-partum
period also include the purchase of non-hospital grade breast feeding equip-
ment.
Lactaon support and lactaon counseling services are covered expenses
when provided in either a group or individual seng.
Well Newborn Nursery Care Expense: Benets include charges for roune
care of a covered newborn child as follows:
• Hospital charges for roune nursery care during the mother’s conne-
ment,
• Physician’s charges for circumcision, and
• Physician’s charges for visits to the newborn child in the hospital and
consultaons.
Pap Smear Screening Expense: Covered Medical Expenses include one rou-
ne annual Pap smear screening (or an alternave cervical cancer screening
test when recommended by a physician or a health care provider), and an
FDA approved human papillomavirus screening test for women age 18 and
older.
Mammogram Expense: Covered Medical Expenses include coverage for
mammograms for screening or diagnosc purposes upon referral of a nurse
praconer, cered nurse-midwife, physician assistant, or physician. Ben-
ets will be paid for Expenses incurred for the following:
• Annually for women 18 years of age or older or at any me when recom-
mended by a women’s healthcare provider for the purpose of check-
ing for lumps and other changes for early detecon and prevenon of
breast cancer
Human Organ Transplant Expense: The organ or ssue donaon and facility
is covered. Travel and housing expenses for the recipient and one care- giver
are limited to $5,000 per transplant. Preauthorizaon required for all trans-
plant expenses.
•11• Portland State University
IMPORTANT NOTICE: This is a brief descripon of the limitaons and exclu-
sions of this policy. For more detailed informaon, you may request the Stu-
dent Guide from PacicSource at hps://PacicSource.com/psu.
Plan benets are subject to all applicable state and federal laws and regula-
ons, which are subject to change. Covered services must be performed in the
least costly seng where they can be provided safely. If a procedure can be
done safely in an outpaent seng, but is performed in a hospital seng, then
this Plan will only pay what it would have been for the procedure on an out-
paent basis. This Plan neither covers nor provides benets for the following:
Types of Treatment – This Student Policy does not cover the following:
• Abdominoplasty for any indicaon.
• Any amounts in excess of the allowable fee for a given service or supply.
• Aversion therapy.
• Benets not stated – Services and supplies not specically described as
benets under this Student Policy and/or any endorsement aached
hereto.
• Biofeedback (other than as specically noted under the Covered Medi-
cal Expenses – Other Covered Medical Services, Supplies, and Treat-
ments secon).
• Charges for phone consultaons, missed appointments, get acquaint-
ed visits, compleon of claim forms, or reports PacicSource needs to
process claims. Charges over the usual, customary, and reasonable fee
(UCR) – Any amount in excess of the UCR for a given service or supply.
• Charges that are the responsibility of a third party who may have caused
the illness, injury, or disease or other insurers covering the incident
(such as workers’ compensaon insurers, automobile insurers, and gen-
eral liability insurers).
• Computer or electronic equipment for monitoring asthmac, diabec,
or similar medical condions or related data.
• Cosmec/reconstrucve services and supplies – Except as specied in
the Student Guide
• Day care or custodial care – Care and related services designed essen-
ally to assist a person in maintaining acvies of daily living. Custodial
care is only covered in conjuncon with respite care allowed under the
Student Guide’s hospice benet.
• Dental examinaons and treatment – Except as noted in the Student
Guide
• Drugs and biologicals that can be self-administered (including inject-
ables), other than those provided in a hospital emergency room, or
other instuonal seng, or as outpaent chemotherapy and dialysis,
which are covered.
• Drugs or medicaons not prescribed for inborn errors of metabolism,
diabec insulin, or ausm spectrum disorder that can be self-adminis-
tered (including prescripon drugs, injectable drugs, and biologicals),
unless given during a visit for outpaent chemotherapy or dialysis or
during a medically necessary hospital, emergency room or other ins-
tuonal stay.
• Experimental or invesgaonal procedures – See Student Guide for de-
tails.
• Eye examinaons (roune) members age 19 and older.
• Eye glasses/Contact Lenses members age 19 and older – The ng, pro-
vision, or replacement of eye glasses, lenses, frames, contact lenses, or
subnormal vision aids intended to correct refracve error.
• Eye exercises, therapy, and procedures – Orthopcs, vision therapy, and
procedures intended to correct refracve errors.
• Family planning – Services and supplies for arcial inseminaon, in
vitro ferlizaon, treatment of inferlity, or surgery to reverse volun-
tary sterilizaon, and treatment of erecle or sexual dysfuncon unless
medically necessary. See Student Guide for details.
• Fitness or exercise programs and health or tness club memberships.
• Foot care (roune) – Services and supplies for corns and calluses of the
feet, condions of the toenails other than infecon, hypertrophy or hy-
perplasia of the skin of the feet, and other roune foot care, except in
the case of paents being treated for diabetes mellitus.
• Genetic (DNA) testing – DNA and other genetic tests, except for those
tests identified as medically necessary for the diagnosis and standard
treatment of specific diseases.
• Growth hormone injections or treatments, except to treat documented
growth hormone deficiencies.
• Hearing Aids for individuals 19 and older except as noted in the Student
Guide.
• Homeopathic medicines or homeopathic supplies.
• Hypnotherapy.
• Immunizations when recommended for or in anticipation of exposure
through work.
• Jaw – Services or supplies for developmental or degenerative abnormali-
ties of the jaw, malocclusion, dental implants, or improving placement
of dentures.
• Massage, massage therapy or neuromuscular re-education, even as part
of a physical therapy program.
• Mattresses and mattress pads are only covered when medically neces-
sary to heal pressure sores.
• Mental health treatments for conditions that are not attributable to a
mental health diagnosis as noted in the Diagnostic and Statistical Manu-
al of Mental Disorders, DSM-IV-TR, Fourth Edition (DSM-IV) or the DSM
of Mental Disorders, Fifth Edition (DSM-5).
• Modifications to vehicles or structures to prevent, treat, or accommo-
date a medical condition.
• Motion analysis, including videotaping and 3-D kinematics, dynamic sur-
face and fine wire electromyography, including physician review.
• Myeloablative high dose chemotherapy, except as noted in the Student
Guide.
• Naturopathic supplies.
• Nicotine related disorders other than those covered under tobacco
cessation program services.
• Obesity or weight control except as noted in the Student Guide
• Orthopedic shoes and shoe modifications.
• Orthognathic surgery – except as noted in the Student Guide
• Over-the-counter medications or nonprescription drugs.
• Physical or eye examinations required for administrative purposes such
as participation in athletics, admission to school, or by an employer.
• Private nursing service.
• Recreation therapy – Outpatient.
• Rehabilitation – Functional capacity evaluations, work hardening pro-
grams, vocational rehabilitation, community reintegration services, and
driving evaluations and training programs.
• Scheduled and/or non-emergent medical care outside of the United
States.
• Services of providers who are not eligible for reimbursement under the
Student Guide.
• Services or supplies provided by the State Department of Health and
Welfare, or through any other government agency.
• Services or supplies for which no charge is made, for which the member
is not legally required to pay, or for which a provider or facility is not
licensed to provide even though the service or supply may otherwise be
eligible. This exclusion includes services provided by the member, or by
an immediate family member.
• Services or supplies received after enrollment in this Student Policy
ends.
• Services required by state law as a condition of maintaining a valid driver
license or commercial driver license.
• Services, supplies, and equipment not involved in diagnosis or treat-
ment but provided primarily for the comfort, convenience, intended to
alter the physical environment, or education of a patient. This includes
appliances like adjustable power beds sold as furniture, air conditioners,
Exclusions and Limitations
Connued on next page
•12• Portland State University
air puriers, room humidiers, heang and cooling pads, home blood
pressure monitoring equipment, light boxes, conveyances other than
convenonal wheelchairs, whirlpool baths, spas, saunas, heat lamps,
tanning lights, and pillows.
• Sexual disorders – Services or supplies for the treatment of sexual dys-
funcon or inadequacy unless medically necessary to treat a mental
health diagnosis.
• Sex reassignment – Procedures, services or supplies related to a sex re-
assignment unless medically necessary.
• Snoring – Services or supplies for the diagnosis or treatment of snoring
and/or upper airway resistance disorders, including somnoplasty.
• Speech therapy – Except if medically necessary as part of a treatment
plan.
• Surgery to reverse voluntary sterilizaon.
• Transplants – Except as noted in the Student Guide.
• Treatment not medically necessary
Exclusions and Limitations (continued)
• Treatment of any illness, injury, or disease resulng from an illegal oc-
cupaon or aempted felony, or treatment received while in the cus-
tody of any law enforcement other than with local supervisory authority
while pending disposion of charges.
• Treatment of any conrmed work-related illness, injury, or disease, ex-
cept as noted in the Student Guide
• Treatment prior to enrollment – Services or supplies a member received
prior to enrolling in coverage provided by this Student Policy, such as in-
paent stays or admission to a hospital, skilled nursing facility or special-
ized facility that began before the paent’s coverage under the Student
Guide.
• Vocaonal rehabilitaon, except as medically necessary and as noted in
the Student Guide.
• War-related condions – The treatment of any condion caused by or
arising out of an act of war, armed invasion, or aggression, or while in
the service of the armed forces unless not covered by the member’s
military or veterans coverage.
Denitions
Wherever used in this policy, the following denions apply to the terms list-
ed below, and the masculine includes the feminine and the singular includes
the plural. Other terms are dened where they are rst used in the text.
Accident means an unforeseen or unexpected event causing injury that re-
quires medical aenon.
Allowable Fee is the dollar amount established by PacicSource for reim-
bursement of charges for specic services or supplies provided by non-par-
cipang providers. PacicSource uses several sources to determine the al-
lowable fee. Depending on the service or supply and the geographical area
in which it is provided, the allowable fee may be based on data collected
from the Centers for Medicare and Medicaid Services (CMS), other naon-
ally recognized databases, or PacicSource, as documented in PacicSource’s
payment policy.
Appeal means a wrien or verbal request from an enrollee or, if authorized
by the enrollee, the enrollee’s authorized representave, to change a previ-
ous decision made by PacicSource concerning;
• Access to healthcare benets, including an adverse benet determina-
on made pursuant to ulizaon management;
• Claims payment, handling or reimbursement for healthcare services;
• Maers pertaining to the contractual relaonship between an Enrollee
and PacicSource;
• Rescissions of enrollee’s benet coverage by PacicSource; and
• Other maers as specically required by law.
Authorized representave is an individual who by law or by the consent of a
person may act on behalf of the person. An authorized representave must
have the enrollee complete and execute an Authorizaon to Use / Disclose
PHI form and a Designaon of Authorized Representave form, both of which
are available at www.pacicsource.com, and which will be supplied to you
upon request. These completed forms must be submied to PacicSource
before PacicSource can recognize the authorized representave as acng
on behalf of the enrollee.
Co-insurance means a dened percentage of the allowable fee for covered
services and supplies the enrollee receives. It is the percentage the enrollee
is responsible for, not including co-pays and deducble.
Contracted Allowable Fee is an amount PacicSource agrees to pay a Parci-
pang Provider for a given service or supply through direct or indirect con-
tract.
Co-payment is a xed up-front dollar amount the enrollee is required to pay
for certain covered services.
Covered Expense is an expense for which benets are payable under this Plan
subject to applicable deducble, co-payment, co-insurance, out-of-pocket
maximum, or other specic limitaons.
Deducble means the poron of the healthcare expense that must be paid
by the enrollee before the benets of this plan are applied.
Dependent means the covered student’s spouse residing with the covered
student or the person idened as a domesc partner in the “Adavit of
Domesc Partnership” which is completed and signed by the covered stu-
dent, and the covered student’s child. The term “child” includes a covered
student’s step-child, adopted child, and a child for whom a peon for adop-
on is pending. The term “dependent” does not include a person who is an
eligible student or a member of the armed forces.
Emergency medical condion means a medical condion:
• That manifests itself by acute symptoms of sucient severity, including
severe pain that a prudent layperson possessing an average knowledge
of health and medicine would reasonably expect that failure to receive
immediate medical aenon would:
□ Place the health of a person, or an unborn child in the case of a
pregnant woman, in serious jeopardy;
□ Result in serious impairment to bodily funcons; or
□ Result in serious dysfuncon of any bodily organ or part.
• With respect to a pregnant woman who is having contracons, for which
there is inadequate me to aect a safe transfer to another hospital
before delivery or for which a transfer may pose a threat to the health or
safety of the woman or the unborn child.
Enrollee means a covered student while coverage under this Plan is in eect.
Generic drugs are drugs that, under federal law, require a prescripon by a
licensed physician (M.D. or D.O.) or other licensed medical provider and are
not a brand name medicaon. By law, generic drugs must have the same ac-
ve ingredients as the brand name medicaon and are subject to the same
standards of their brand name counterpart.
Injury means bodily trauma or damage that is independent of disease or in-
rmity. The damage must be caused solely through external and accidental
means and does not include muscular strain sustained while performing a
physical acvity.
Medically necessary means those services and supplies that are required for
diagnosis or treatment of illness, injury, or disease and that are:
• Consistent with the symptoms or diagnosis and treatment of the
condition;
• Consistent with generally accepted standards of good medical practice
in Oregon, or expert consensus physician opinion published in peer-re-
viewed medical literature, or the results of clinical outcome trials pub-
lished in peer-reviewed medical literature;
Connued on next page
•13• Portland State University
Denitions (continued)
• As likely to produce a signicant posive outcome as, and no more likely
to produce a negave outcome than, any other service or supply, both
as to the illness, injury, or disease involved and the paent’s overall
health condion;
• Not for the convenience of the enrollee or a provider of services or sup-
plies; and
• The least costly of the alternave services or supplies that can be safely
provided. When specically applied to a hospital inpaent, it further
means that the services or supplies cannot be safely provided in other
than a hospital inpaent seng without adversely aecng the paent’s
condion or the quality of medical care rendered.
Services and supplies intended to diagnose or screen for a medical condion
in the absence of signs or symptoms, or of abnormalies on prior tesng,
including exposure to infecous or toxic materials or family history of genec
disease, are not considered medically necessary under this denion.
Non-Parcipang Provider is a provider of covered medical services or sup-
plies that does not directly or indirectly hold a provider contract or agree-
ment with PacicSource.
Parcipang Provider means a physician, healthcare professional, hospi-
tal, medical facility, or supplier of medical supplies that directly or indirectly
holds a provider contract or agreement with PacicSource.
Physician means a state-licensed Doctor of Medicine (M.D.) or a Doctor of
Osteopathy (D.O.).
Plan means the Student Health Insurance Plan, sponsored by Portland State
University as documented by the Policy and PacicSource Health Plans.
Prescripon drugs are drugs that, under federal law, require a prescripon by
a licensed physician (M.D. or D.O.) or other licensed medical provider.
Schedule of Benets is a summary of the policy issued or applied for, not a
contract of insurance that includes a list of principle benets and coverages,
and a statement of the limitaons and exclusions contained in the policy.
Student means a student of the Policyholder who is insured under this Plan.
Usual, customary, and reasonable fee (UCR) is the dollar amount established
by PacicSource for reimbursement of eligible charges for specic services
or supplies provided by non-parcipang providers. PacicSource uses sev-
eral sources to determine UCR. Depending on the service or supply and the
geographical area in which it is provided, UCR may be based on data col-
lected from the Centers for Medicare and Medicaid Services (CMS), other
naonally recognized databases, or PacicSource, as documented in Pacic-
Source’s payment policy. A Non-Parcipang Provider may charge more than
the limits established by the denion of UCR. Charges that are eligible for
reimbursement but exceed the UCR are the enrollee’s responsibility.
Emergency Assistance Services: On Call International
On Call Global Response Center:
877-318-6901 (Toll-free within the U.S.)
603-328-1909 (Outside the U.S.)
One Delaware Drive
Salem, NH 03079
E-mail: mail@oncallinternaonal.com
www.oncallinternaonal.com
On Call Internaonal does not replace your medical insurance. All medical
costs incurred should be submied to your health plan and are subject to the
Master Policy limits of your health coverage. All assistance services must be
arranged and provided by On Call Internaonal. Claims for reimbursement
will not be accepted.
Program Guidelines
U.S. students studying in a U.S. locaon are eligible for services when travel-
ing more than 100 miles away from their permanent residence or campus
locaon for up to one year. Medical transportaon services and repatriaon
of deceased remains services are available at campus locaon.*
U.S. students studying abroad are eligible for services both at and away from
their new campus locaon for up to one year.*
Foreign naonal students studying in the U.S. are eligible for On Call Interna-
onal’s services, both on or away from campus or while traveling in a country
that is not their country of origin.*
*Member shall be eligible for services during the term of his/her dened Pro-
gram as long as his/her program is sll eecve and the membership fee
has been paid prior to departure. All care and travel coordinated through
OnCall, no retroacve benets will be granted and no reimbursement will be
approved.
Key Services
Emergency Medical Evacuaon
If adequate medical facilies are not available locally, On Call will make ar-
rangements to use whatever mode of transport, equipment and medical per-
sonnel necessary to evacuate a member to the nearest facility capable of
providing a high standard of care.
Medical Repatriaon
If aer seeking medical aenon, it is medically advisable for the member
to seek further care at home, On Call will transport the member home or to
a medical facility closer to home with a medical or non-medical escort, as
necessary.
Compassionate Visit
If a member is traveling alone and will be hospitalized for more than seven
days, On Call will provide economy, round-trip, common carrier transporta-
on to the place of hospitalizaon and arrange lodging for a designated fam-
ily member or friend.
Care of Minor Children
If a member is traveling with dependent children and is hospitalized as a re-
sult of a medical emergency for more than seven days, On Call will arrange
for the transportaon of the unaended children to their home, with an at-
tendant if necessary.
Return of Deceased Remains
On Call will assist with the logiscs of returning a member’s remains home in
the event of his or her death. This service includes arranging the preparaon
of the remains for transport, procuring required documentaon, providing
the necessary shipping container as well as paying for transport.
Prescripon Assistance
If a member needs a replacement prescripon while traveling, On Call will
assist in lling that prescripon. Any expenses associated with prescripon
replacement are the member’s responsibility.
Emergency Message Transmission
On Call will receive and transmit authorized emergency messages for members.
Legal Consultaon and Referral
If a member is away from home and requires the services of an aorney,
On Call shall arrange for an inial telephone consultaon with an aorney
without charge to the member. If necessary, the member will be referred to
a local aorney.
Lost Luggage Assistance
On Call will assist the member with the tracking of luggage lost or delayed in
transit.
Lost/Stolen Travel Document Assistance
On Call will provide assistance by arranging for the replacement of passports,
visas, airline documents, birth cercates and other travel-related docu-
ments. Any expenses related to replacing lost travel documents are the mem-
ber’s responsibility.
Interpreter & Legal Referrals
On Call will refer members to local translators and interpreters if communica-
on problems cannot be solved via telephone.
Connued on next page
•14• Portland State University
Pre-trip Informaon
On Call oers members reports via email, fax or postal mail including visa,
passport and inoculaon requirements, cultural informaon, weather con-
dions, embassy and consulate referrals, foreign exchange rates, and travel
advisories for any desnaon.
As a member, you can call upon doctors, hospitals, pharmacies and other ser-
vices whenever traveling 100 miles or more from your permanent address,
campus locaon or abroad, 24 hours a day, 365 days a year. One phone call
connects you to a state-of-the art Global Response Center staed around-the-
clock with trained mullingual professionals to handle medical emergencies
quickly and eciently. As the U.S. member of the Internaonal Assistance
Group, a 36-partner global network of independent assistance companies,
including more than 53 alarm centers, On Call Internaonal has immediate
response capabilies worldwide with a global network of pre-qualied medi-
cal providers, including air and ground ambulance services.
Condions & Exclusions
On Call Internaonal will not pay for services in the following instances:
• Services rendered without the coordinaon and approval of On Call
• Intenonally self-inicted injuries, suicide or any aempted threat ex-
cept when hospitalized as an inpaent.
• Expenses incurred if the original or ancillary purpose of the member’s
trip is to obtain medical treatment.
• Parcipaon in a declared or undeclared act of war, civil disturbance
or insurrecon or an accident occurring while the member is serving
on full-me or acve duty in the Armed Forces of any country. *Par-
cipaon in an internaonal authority ight in aircra being used for
experimental purpose, or in military aircra (except the Military Aircra
Command of the United States or similar air transport Services Account
of other) or while serving as a member of the crew of any aircra.
• Use of any alcohol or drug unless prescribed by a physician or except if
hospitalized as an inpaent. *Any services provided to an injured per-
son where the member is entled to receive reimbursement for such
expenses under any group insurance program maintained by the mem-
ber’s insurance company or employer.
• Roune or non-disabling medical problems, such as simple fractures, or
sickness, which can be treated by local doctors and do not prevent the
injured person from connuing the trip or returning home.
• Any treatment or expense related to childbirth, miscarriage or pregnan-
cy except for any abnormal pregnancy or vital complicaon of pregnancy
which endangers the life of the mother and/or unborn child during the
rst twenty-four weeks of pregnancy.
• A member on an organ transplant list prior to enrollment will not be
entled to a transport for that transplant.
On Call cannot be held responsible for failure to provide services or for delays
caused by condions beyond its control including, but not limited to, ight
or weather condions, strikes, unforeseen changes to airport regulaons or
restricons, failure to comply with On Call’s recommendaons, or where ren-
dering of service is prohibited by local laws or regulatory agencies.
Member may be required to release On Call or any healthcare provider from
liability during emergency evacuaon and/or repatriaon.
Without liming the foregoing, On Call’s acons and obligaons under this
Agreement are ministerial in nature, and all medical care is provided by medi-
cal professionals ulmately selected by a Member. On Call is not liable for
any malpracce performed by a local doctor, healthcare provider, or aorney.
On Call, at its sole discreon, will assist Members on a fee-for-service basis for
intervenons falling under the Limitaons and Uncovered Services. On Call
reserves the right, at its sole discreon, to request addional nancial guar-
antees or pre-payment or indemnicaon from the Member prior to render-
ing such service on a fee-for-service basis.
Emergency Assistance Services Provided by: On Call Internaonal
877-318-6901(Toll-free within the U.S.)
603-328-1909 (Outside the U.S.)
www.oncallinternaonal.com
Emergency Assistance Services: On Call International (continued)
•15• Portland State University
Center for Student Health and Counseling (SHAC)
SHAC provides high quality, accessible, medical, counseling, dental, test-
ing and health promoon services to PSU students. SHAC has an incredible
staof health care professionals who are all dedicated to keeping students
healthy so they can stay in the classroom and focus on learning.
Located at 1880 SW 6th Avenue
University Center Building
(503) 725-2800
www.pdx.edu/shac
(503) 725-2800
(503) 725-2611
(503) 725-2551
Medical & Counseling: Suite 200
Dental Services: Suite 307
Tesng Services: Suite 340
SHAC Eligibility and Cost
All PSU students taking 5 or more in-load, non-restricted dierenal credits
are eligible to use SHAC Services (1 credit to use SHAC Dental Services).
A health fee of $156 per term is included in student tuition (for those
taking 5 or more in-load, non-restricted differential credits), and covers the
cost of most SHAC services, regardless of which health insurance plan the
student carries.
• Medical Services have minimal to no extra charge.
• Learning Disability and ADHD Assessments require a fee.
• Counseling Services are covered by the student health fee.
• Dental fees are generally much lower than private clinics. For current
dental fees visit www.pdx.edu/shac/dental-fees.
• Student Tesng Services is open to all students and the community.
There are fees for most services.
Closest Hospitals in Case of Emergency:
OHSU: (503) 494-8311
3181 SW Sam Jackson Park Rd., Portland, OR 97239
Legacy Good Samaritan Hospital: (503) 413-7074
1015 NW 22nd Ave., Portland, OR 97210
Closest Urgent Care Centers:
Providence Medical Group: (503) 215-9900
Locaons throughout Portland
Legacy Urgent Care - Good Samaritan: (503) 413-8090
1015 NW 22nd Ave., Portland, OR 97210
Urgent Care - Legacy GoHealth:
Visit www.gohealthuc.com for wait mes
at many Portland and Vancouver locaons
To verify parcipaon of these providers in the PacicSource network,
you can use PacicSource’s online provider directory located at
hps://PacicSource.com/psu.
This material is for informaon only and is not an oer or invitaon to contract. Health insurance plans contain exclusions, limitaons and benet maximums. Providers are in-
dependent contractors and are not agents of PacicSource. Provider parcipaon may change without noce. PacicSource does not provide care or guarantee access to health
services. Informaon is believed to be accurate as of the producon date; however, it is subject to change.
NOTICE: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person les an applicaon for insurance or statement of claim
containing any materially false informaon or who conceals for the purpose of misleading, informaon concerning any fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penales.
IMPORTANT NOTE
The Portland State University Student Health Insurance Plan is underwrien by PacicSource Health Plans and administered by PacicSource Health Plans.
USI INSURANCE SERVICES PRIVACY INFORMATION
We know that your privacy is important to you and we strive to protect the condenality of your personal informaon. We do not disclose any personal informaon about our plan
parcipants, except as permied or required by law (e.g., informaon you provide to us may be shared with your school to process your insurance transacon). To protect your personal
informaon from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured les and buildings.
You may obtain a detailed copy of our privacy policy through your school or by calling us at (800) 853-5899 or by vising us at hp://www.usi.com/privacy.