Plan Brochure - Health Insurance Quotes

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Choose the Perfect Plan for You PacificSource offers an array of health plans to meet the needs of Montana individuals and families. 4 Eligibility You may apply for a PacificSource Individual and Family policy if you are a Montana resident and you are not covered by Medicare.You may also apply to include your legal spouse and domestic partner, as well as dependent children under the age of 26. Coverage effective dates After you return your policy application to PacificSource, your application is reviewed and underwritten. We will then offer you coverage or decline coverage based on your health. If we offer you coverage, your policy can become effective on either the 1st or the 15th of the month following approval. Premiums The standard premium schedule for our plans is available on our website, PacificSource.com, or by contacting our Individual Sales Department at (888) 684-5585. Rates are based on the age of each family member on your policy. If you add or subtract family members from your coverage, the premium will be adjusted as requested and approved by PacificSource. PacificSource reviews its premium rates annually. If a rate adjustment is needed, we will notify you 45 days in advance. Apply online Compare plans, view rates, and apply online! Visit our website at PacificSource.com and find the health plan that best fits your budget and needs in one easy location. All plans cover treatment for illness and injury, preventive care, maternity care, and prescription drugs. Benefits begin for a single family member once the individual deductible has been met, or the family deductible is met for two or more covered persons, whichever comes first. Coverage levels differ from plan to plan, and some plans also cover alternative practitioner services. All plans have an overall annual maximum benefit of $2 million. For more details, please see the “Plans At-a-Glance” benefit comparison on the following page.
Plans At-a-Glance Individual Annual Deductible/Out-of- Pocket (OOP) Limit (limit includes the deductible) Accident Benefit (accident-related covered expenses) Preventive Care Preferred Value HSA Qualified Uniform Deductible/OOP Limit $1,000/$6,000 $2,500/$7,500 $5,000/$10,000 The first $1,000 of covered expense within 90 days of an accident is paid at 100% and is not subject to the deductible. The balance is covered as shown below. Deductible/OOP Limit $5,000/$10,000 $7,500/$12,500 $10,000/$15,000 Deductible/OOP Limit $3,000/$6,050 $6,050/$6,050 The first $500 of covered expense within 90 days of an accident is paid at 100% and is not subject to the deductible. The balance is covered as shown below. Preferred Provider Benefit (member’s responsibility shown below) Deductible/OOP Limit $1,000/$5,000 Not covered Well Child Care Covered in full l� Covered in full l� Covered in full l� Covered in full l� Routine Physicals and Preventive Care Exams Covered in full l� Covered in full l� Covered in full l� Covered in full l� Routine Gynecological Exams Covered in full l Covered in full l Covered in full l Covered in full l Immunizations Covered in full l Covered in full l Covered in full l Covered in full l Professional Services Office and Home Visits $30 copay l 40% 50% � 50% Chiropractic $30 copay l 40% 50% � 50% Naturopathic Care $30 copay l 40% 50% � Not covered Urgent Care Visits $30 copay l 40% 50% � 50% Maternity Care 30% 40% 50% � 50% Hospital Services 30% 40% 50% � 50% Outpatient Services 30% 40% 50% � 50% 30% after $100 copay 50% after $150 copay Emergency Room Visits (copay waived if admitted to hospital) 40% 50% � (copay waived if admitted to hospital) Other Covered Services Incentive drugs: $4 l 50% 50% � 50% Prescription Drugs Generic and brand name drugs: 50% l Outpatient Rehabilitative Services 30% 40% 50% � 50% Allergy Injections 30% 40% 50% � 50% Ambulance Service 30% 40% 50% � 50% Inpatient Mental Health 30% 40% 50% � 50% Vision (per two calendar years) Exam: $30 copay l Hardware: covered in full up to $200 max l Not covered l Not subject to the annual deductible. � Scheduled benefit. � Covered in full under the Individual and Family HSA $6,050 plan (after deductible). All benefits shown here apply for participating providers. Services rendered by nonparticipating providers will be paid at a lower percentage. For more details, see the summary of benefits on pages 9, 11, 13, and 15. 5
Page 1 and 2: Individual and Family Plans Well-Ba
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Plan Brochure - Health Insurance Quotes

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