PacificSource SmartAlliance Value Bronze 3000 ID

Plan Information
Company PacificSource Health Plans
State ID
Metal Tier Bronze
Plan Type HMO

Cost Sharing Benefits

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.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $3,000 $12,000
Deductible (Family) $6,000 $24,000
Coinsurance 50% 75%
Out of Pocket Maximum (Individual) $6,350 $24,000
Out of Pocket Maximum (Family) $12,700 $48,000
Services In Network Out of Network
Primary Care Visit 50% Coinsurance after deductible 75% coinsurance
Specialist Visit 50% Coinsurance after deductible 75% coinsurance
In Patient Hospital Services 50% Coinsurance after deductible 75% coinsurance
Emergency Room Services 50% Coinsurance after deductible 50% coinsurance
Mental / Behavioral Health 50% coinsurance 75% coinsurance
Imaging (CT/PET Scans, MRIs) 50% coinsurance 75% coinsurance
Rehabilitative Speech Therapy 50% coinsurance 75% coinsurance
Rehabilitative Occupational & Physical Therapy 50% coinsurance 75% coinsurance
Preventative Care $0 75% coinsurance
Laboratory Outpatient and Professional Services 50% coinsurance 75% coinsurance
X-ray and Diagnostic Imaging 50% coinsurance 75% coinsurance
Outpatient Facility 50% coinsurance 75% coinsurance
Outpatient Surgery 50% coinsurance 75% coinsurance
Prescription Drugs In Network Out of Network
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.

Plan Name
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