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Benefit Summaries and Forms
BENEFIT SUMMARIES AND FORMS
Forms and Materials
Request for Group Insurance
Group Health/Dental Enrollment Application
Waiver of Insurance
Plan Summaries
Medical
CoDeduct Value 500+35/80
CoDeduct Value 500+35/70
CoDeduct Value 1000+45/80
CoDeduct Value 1000+45/70
CoDeduct Value 2000+35/80
CoDeduct Value 2500+45/70
CoDeduct Value 5000+45/70
Preferred 50/3750
Preferred HSA 80/3000
Pharmacy
Tiered 15/30/45 Mac B Pharmacy Plan
Tiered 10/50/75 Mac B Pharmacy Plan
$15/50% $2500 Value Pharmacy Plan
Ancillary Benefits
Alternative & Chiropractic 10/1000
Alternative & Chiropractic (HSA option)
Preventive Care First Dollar (HSA)
Vision
High Option
Standard Option
Dental
Plan 1000
Plan 1500
Preventive Only
Orthodontia 1500
(Only available to groups with 26+ enrolled)
Spanish Plan Summaries
Ancillary Benefits
Alternative & Chiropractic (HSA option)
No-Cost Extras for PacificSource Members
PacificSource members have access to extra benefits and services as part of their medical coverage.
PacificSource Value-Added Programs and Services
PacificSource Extras member flier (for groups with 51 or more employees)
The Forms and Materials for Oregon Agents
page provides links to download sales and member fliers for many of our value-added programs and services.