PacificSource SmartAlliance Value Bronze 3000 (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) $3,000
Deductible (Family) $6,000
Coinsurance 50%
Out of Pocket Maximum (Individual) $6,350
Out of Pocket Maximum (Family) $12,700

Doctors Visits

Primary Care Visit 50% Coinsurance after deductible
Specialist Visit 50% Coinsurance after deductible
In Patient Hospital Services 50% Coinsurance after deductible
Emergency Room Services 50% Coinsurance after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 50% coinsurance
Laboratory Outpatient and Professional Services 50% coinsurance
X-ray and Diagnostic Imaging 50% coinsurance

Other

Mental / Behavioral Health 50% coinsurance
Rehabilitative Speech Therapy 50% coinsurance
Rehabilitative Occupational & Physical Therapy 50% coinsurance
Outpatient Facility 50% coinsurance
Outpatient Surgery 50% coinsurance

Prescription Drugs

Generic Rx 50% Coinsurance after deductible
Preferred Brand Rx 50% Coinsurance after deductible
Non Preferred Brand Rx 50% Coinsurance after deductible
Specialty Drugs 50% Coinsurance after deductible

Other Plans

Other plans that are available in the state.

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