PacificSource - PSN Gold 1500

Montana, 2017

  • Plan Type

    PPO

  • Metal Tier

    Gold

  • Out of Pocket Maximum

    $3,000

  • Deductible

    $1,500

Enroll Now
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Call (855) 866-5590 to speak with a licensed agent about a new health plan.

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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) $1,500
Deductible (Family) $3,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $3,000
Out of Pocket Maximum (Family) $6,000

Doctor Visits

Primary Care Visit 20% Coinsurance after deductible
Specialist Visit 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible
Emergency Room Services 20% Coinsurance after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 20% Coinsurance after deductible
Laboratory Outpatient and Professional Services 20% Coinsurance after deductible
X-Ray and Diagnostic Imaging 20% Coinsurance after deductible

Health Management Programs

Asthma Available
Depression Not available
Diabetes Available
Heart Disease Available
High Blood Pressure / High Cholesterol Not available
Lower Back Pain Not available
Pain Management Not available
Pregnancy Available
Weight Loss Not available

Other

Mental / Behavioral Health Inpatient 20% Coinsurance after deductible
Mental / Behavioral Health Outpatient 20% Coinsurance after deductible
Rehabilitative Speech Therapy 20% Coinsurance after deductible
Rehabilitative Occupational & Physical Therapy 20% Coinsurance after deductible
Outpatient Facility 20% Coinsurance after deductible
Outpatient Surgery 20% Coinsurance after deductible

Prescription Drugs

Generic Rx Data Not Available
Preferred Brand Rx Data Not Available
Non Preferred Brand Rx Data Not Available
Specialty Drugs

Other Plans in Montana

Plan SmartHealth Silver HSA 3000 Deductible $3,000 Coinsurance Not applicable Out of Pocket $5,000
Plan SmartHealth Bronze HSA 6550 Deductible $6,550 Coinsurance Not applicable Out of Pocket $6,550
Plan PSN Silver HSA 3000 Deductible $3,000 Coinsurance Not applicable Out of Pocket $5,000
Plan SmartHealth Gold 1500 Deductible $1,500 Coinsurance Not applicable Out of Pocket $3,000
Plan PSN Bronze HSA 6550 Deductible $6,550 Coinsurance Not applicable Out of Pocket $6,550
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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) $1,500
Deductible (Family) $3,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $3,000
Out of Pocket Maximum (Family) $6,000

Doctor Visits

Primary Care Visit 20% Coinsurance after deductible
Specialist Visit 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible
Emergency Room Services 20% Coinsurance after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 20% Coinsurance after deductible
Laboratory Outpatient and Professional Services 20% Coinsurance after deductible
X-Ray and Diagnostic Imaging 20% Coinsurance after deductible

Health Management Programs

Asthma Available
Depression Not available
Diabetes Available
Heart Disease Available
High Blood Pressure / High Cholesterol Not available
Lower Back Pain Not available
Pain Management Not available
Pregnancy Available
Weight Loss Not available

Other

Mental / Behavioral Health Inpatient 20% Coinsurance after deductible
Mental / Behavioral Health Outpatient 20% Coinsurance after deductible
Rehabilitative Speech Therapy 20% Coinsurance after deductible
Rehabilitative Occupational & Physical Therapy 20% Coinsurance after deductible
Outpatient Facility 20% Coinsurance after deductible
Outpatient Surgery 20% Coinsurance after deductible

Prescription Drugs

Generic Rx Data Not Available
Preferred Brand Rx Data Not Available
Non Preferred Brand Rx Data Not Available
Specialty Drugs

Other Plans in Montana

Plan SmartHealth Silver HSA 3000 Deductible $3,000 Coinsurance Not applicable Out of Pocket $5,000
Plan SmartHealth Bronze HSA 6550 Deductible $6,550 Coinsurance Not applicable Out of Pocket $6,550
Plan PSN Silver HSA 3000 Deductible $3,000 Coinsurance Not applicable Out of Pocket $5,000
Plan SmartHealth Gold 1500 Deductible $1,500 Coinsurance Not applicable Out of Pocket $3,000
Plan PSN Bronze HSA 6550 Deductible $6,550 Coinsurance Not applicable Out of Pocket $6,550