PacificSource - PSN Silver HSA 3000

Montana, 2017

  • Plan Type

    PPO

  • Metal Tier

    Silver

  • Out of Pocket Maximum

    $5,000

  • Deductible

    $3,000

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) $3,000
Deductible (Family) $6,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $5,000
Out of Pocket Maximum (Family) $10,000

Doctor Visits

Primary Care Visit 25% Coinsurance after deductible
Specialist Visit 25% Coinsurance after deductible
Inpatient Facility 25% Coinsurance after deductible
Inpatient Physician 25% Coinsurance after deductible
Emergency Room Services 25% Coinsurance after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 25% Coinsurance after deductible
Laboratory Outpatient and Professional Services 25% Coinsurance after deductible
X-Ray and Diagnostic Imaging 25% 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 25% Coinsurance after deductible
Mental / Behavioral Health Outpatient 25% Coinsurance after deductible
Rehabilitative Speech Therapy 25% Coinsurance after deductible
Rehabilitative Occupational & Physical Therapy 25% Coinsurance after deductible
Outpatient Facility 25% Coinsurance after deductible
Outpatient Surgery 25% Coinsurance after deductible

Prescription Drugs

Generic Rx 25% Coinsurance after deductible
Preferred Brand Rx 25% Coinsurance after deductible
Non Preferred Brand Rx 25% Coinsurance after deductible
Specialty Drugs 25% Coinsurance after deductible

73% Cost Sharing Benefits

Households with incomes between 200% to 250% of FPL qualify for the following cost sharing benefits for this silver plan. To understand how cost sharing reductions work and how they work for you see our article about Obamacare Cost Sharing Reduction Discounts

Deductibles and Cost Sharing

Deductible (Individual) $1,800
Deductible (Family) $3,600
Out of Pocket Maximum (Individual) $5,000
Out of Pocket Maximum (Family) $10,000

Doctor Visits

Primary Care Physician 25% Coinsurance after deductible
Specialists 25% Coinsurance after deductible
Emergency Room 25% Coinsurance after deductible
Inpatient Facility 25% Coinsurance after deductible
Inpatient Physician 25% Coinsurance after deductible

Prescription Drugs

Generic Rx 25% Coinsurance after deductible
Preferred Brand Rx 25% Coinsurance after deductible
Non Preferred Brand Rx 25% Coinsurance after deductible
Specialty Drugs 25% Coinsurance after deductible

87% Cost Sharing Benefits

Households with incomes between 150% to 200% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing

Deductible (Individual) $750
Deductible (Family) $1,500
Out of Pocket Maximum (Individual) $1,500
Out of Pocket Maximum (Family) $3,000

Doctor Visits

Primary Care Physician 20% Coinsurance after deductible
Specialists 20% Coinsurance after deductible
Emergency Room 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible

Prescription Drugs

Generic Rx 20% Coinsurance after deductible
Preferred Brand Rx 20% Coinsurance after deductible
Non Preferred Brand Rx 20% Coinsurance after deductible
Specialty Drugs 20% Coinsurance after deductible

94% Cost Sharing Benefits

Households with incomes between 138% to 150% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing

Deductible (Individual) $250
Deductible (Family) $500
Out of Pocket Maximum (Individual) $600
Out of Pocket Maximum (Family) $1,200

Doctor Visits

Primary Care Physician 20% Coinsurance after deductible
Specialists 20% Coinsurance after deductible
Emergency Room 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible

Prescription Drugs

Generic Rx 20% Coinsurance after deductible
Preferred Brand Rx 20% Coinsurance after deductible
Non Preferred Brand Rx 20% Coinsurance after deductible
Specialty Drugs 20% Coinsurance after deductible

Other Plans in Montana

Plan SmartHealth Silver HSA 3000 Deductible $3,000 Coinsurance Not applicable Out of Pocket $5,000
Plan PSN Gold 1500 Deductible $1,500 Coinsurance Not applicable Out of Pocket $3,000
Plan SmartHealth Bronze HSA 6550 Deductible $6,550 Coinsurance Not applicable Out of Pocket $6,550
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) $3,000
Deductible (Family) $6,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $5,000
Out of Pocket Maximum (Family) $10,000

Doctor Visits

Primary Care Visit 25% Coinsurance after deductible
Specialist Visit 25% Coinsurance after deductible
Inpatient Facility 25% Coinsurance after deductible
Inpatient Physician 25% Coinsurance after deductible
Emergency Room Services 25% Coinsurance after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 25% Coinsurance after deductible
Laboratory Outpatient and Professional Services 25% Coinsurance after deductible
X-Ray and Diagnostic Imaging 25% 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 25% Coinsurance after deductible
Mental / Behavioral Health Outpatient 25% Coinsurance after deductible
Rehabilitative Speech Therapy 25% Coinsurance after deductible
Rehabilitative Occupational & Physical Therapy 25% Coinsurance after deductible
Outpatient Facility 25% Coinsurance after deductible
Outpatient Surgery 25% Coinsurance after deductible

Prescription Drugs

Generic Rx 25% Coinsurance after deductible
Preferred Brand Rx 25% Coinsurance after deductible
Non Preferred Brand Rx 25% Coinsurance after deductible
Specialty Drugs 25% Coinsurance after deductible

73% Cost Sharing Benefits

Households with incomes between 200% to 250% of FPL qualify for the following cost sharing benefits for this silver plan. To understand how cost sharing reductions work and how they work for you see our article about Obamacare Cost Sharing Reduction Discounts

Deductibles and Cost Sharing

Deductible (Individual) $1,800
Deductible (Family) $3,600
Out of Pocket Maximum (Individual) $5,000
Out of Pocket Maximum (Family) $10,000

Doctor Visits

Primary Care Physician 25% Coinsurance after deductible
Specialists 25% Coinsurance after deductible
Emergency Room 25% Coinsurance after deductible
Inpatient Facility 25% Coinsurance after deductible
Inpatient Physician 25% Coinsurance after deductible

Prescription Drugs

Generic Rx 25% Coinsurance after deductible
Preferred Brand Rx 25% Coinsurance after deductible
Non Preferred Brand Rx 25% Coinsurance after deductible
Specialty Drugs 25% Coinsurance after deductible

87% Cost Sharing Benefits

Households with incomes between 150% to 200% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing

Deductible (Individual) $750
Deductible (Family) $1,500
Out of Pocket Maximum (Individual) $1,500
Out of Pocket Maximum (Family) $3,000

Doctor Visits

Primary Care Physician 20% Coinsurance after deductible
Specialists 20% Coinsurance after deductible
Emergency Room 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible

Prescription Drugs

Generic Rx 20% Coinsurance after deductible
Preferred Brand Rx 20% Coinsurance after deductible
Non Preferred Brand Rx 20% Coinsurance after deductible
Specialty Drugs 20% Coinsurance after deductible

94% Cost Sharing Benefits

Households with incomes between 138% to 150% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing

Deductible (Individual) $250
Deductible (Family) $500
Out of Pocket Maximum (Individual) $600
Out of Pocket Maximum (Family) $1,200

Doctor Visits

Primary Care Physician 20% Coinsurance after deductible
Specialists 20% Coinsurance after deductible
Emergency Room 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible

Prescription Drugs

Generic Rx 20% Coinsurance after deductible
Preferred Brand Rx 20% Coinsurance after deductible
Non Preferred Brand Rx 20% Coinsurance after deductible
Specialty Drugs 20% Coinsurance after deductible

Other Plans in Montana

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