PacificSource SmartAlliance Balance Bronze 6350 (Idaho)

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Company PacificSource Health Plans
Plan Year 2014
State Idaho
Metal Tier Bronze
Plan Type HMO
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Cost Sharing Benefits (In Network)

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $6,350
Deductible (Family) $12,700
Coinsurance Data Not Available
Out of Pocket Maximum (Individual) $6,350
Out of Pocket Maximum (Family) $12,700

Doctors Visits

Primary Care Visit $50 Copay before deductible
Specialist Visit $50 Copay before deductible
In Patient Hospital Services No Charge after deductible
Emergency Room Services No Charge after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) No charge
Laboratory Outpatient and Professional Services No charge
X-ray and Diagnostic Imaging No charge


Mental / Behavioral Health First 3 combined visits $50 co-pay/visit, then No charge
Rehabilitative Speech Therapy No charge
Rehabilitative Occupational & Physical Therapy No charge
Outpatient Facility No charge
Outpatient Surgery No charge

Prescription Drugs

Generic Rx $10 Copay before deductible
Preferred Brand Rx No Charge after deductible
Non Preferred Brand Rx No Charge after deductible
Specialty Drugs No Charge after deductible

Other Plans

Other plans that are available in the state.

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