Sample Plan Summaries for Idaho

The sample summaries below are approved PacificSource employer plan designs. At enrollment, members receive customized benefit books showing their specific benefits, lifetime maximums, and any optional coverage provided by the employer. For group-specific member benefit summaries, or previously offered summaries, contact your regional PacificSource office.

Group Medical Plans

Preferred CoDeduct Plans

500+20/80%	1000+40/70%	3000+40/80%
500+30/80%	1500+20/80%	3000+40/70%
500+30/70%	1500+30/80%	5000+20/80%
500+40/80%	1500+30/70%	5000+30/80%
500+40/70%	1500+40/80%	5000+30/70%
750+20/80%	1500+40/70%	5000+40/80%
750+30/80%	2000+20/80%	5000+40/70%
750+30/70%	2000+30/80%	7500+20/80%
750+40/80%	2000+30/70%	7500+30/80%
750+40/70%	2000+40/80%	7500+30/70%
1000+20/80%	2000+40/70%	7500+40/80%
1000+30/80%	3000+20/80%	7500+40/70%
1000+30/70%	3000+30/80%
1000+40/80%	3000+30/70%

Effective October 1, 2010:

500+20/80%	1000+40/70%	3000+40/80%
500+30/80%	1500+20/80%	3000+40/70%
500+30/70%	1500+30/80%	5000+20/80%
500+40/80%	1500+30/70%	5000+30/80%
500+40/70%	1500+40/80%	5000+30/70%
750+20/80%	1500+40/70%	5000+40/80%
750+30/80%	2000+20/80%	5000+40/70%
750+30/70%	2000+30/80%	7500+20/80%
750+40/80%	2000+30/70%	7500+30/80%
750+40/70%	2000+40/80%	7500+30/70%
1000+20/80%	2000+40/70%	7500+40/80%
1000+30/80%	3000+20/80%	7500+40/70%
1000+30/70%	3000+30/80%
1000+40/80%	3000+30/70%

Preferred Deductible and Percentage Plans

80+500	70+500	50+1000
80+750	70+750	50+2000
80+1000	70+1000	50/3500
80+1500	70+1500
80+2000	70+2000
80+3000	70+3000
80+5000	70+5000
80+7500	70+7500

Effective October 1, 2010:

80+500	70+500	50+1000
80+750	70+750	50+2000
80+1000	70+1000	50/3500
80+1500	70+1500
80+2000	70+2000
80+3000	70+3000
80+5000	70+5000
80+7500	70+7500

Preferred HSA Plans

Rx Subject to Deductible:	No Rx Coverage:
HSA 80+1500+Rx	HSA 80+1500
HSA 80+2000+Rx	HSA 80+2000
HSA 80+3000+Rx	HSA 80+3000
HSA 100+5000+Rx	HSA 100+5000

Effective October 1, 2010:

Rx Subject to Deductible:	No Rx Coverage:
HSA 80+1500+Rx	HSA 80+1500
HSA 80+2000+Rx	HSA 80+2000
HSA 80+3000+Rx	HSA 80+3000

SmartHealth for Business Plans

1000+30-45/2500	2500+30-45/2500	5000+30-45/2500
1000+30-45/5000	2500+30-45/5000	5000+30-45/5000
1000+40-55/2500	2500+40-55/2500	5000+40-55/2500
1000+40-55/5000	2500+40-55/5000	5000+40-55/5000
HSA 75+3000

Effective October 1, 2010:

1000+30-45/2500	2500+30-45/2500	5000+30-45/2500
1000+30-45/5000	2500+30-45/5000	5000+30-45/5000
1000+40-55/2500	2500+40-55/2500	5000+40-55/2500
1000+40-55/5000	2500+40-55/5000	5000+40-55/5000
HSA 75+3000

Traditional Plans

80+5000 2000	1500+30/80% 1500	2000+30/80% 2000
750+20/80% 1500	1500+30/80% 2000	2000+30/80% 3000
750+30/80% 2000	1500+30/80% 3000	3000+30/70% 3000
1000+30/70% 2000	1500+40/70% 3000	3000+40/70% 1500
1000+30/80% 1500	1500+40/80% 2000	5000+30/70% 3000
1500+20/80% 2000	2000+20/80% 1500	5000+40/80% 1500
1500+30/70% 3000	2000+30/70% 2000

Effective October 1, 2010:

80+5000 2000	1500+30/80% 1500	2000+30/80% 2000
750+20/80% 1500	1500+30/80% 2000	2000+30/80% 3000
750+30/80% 2000	1500+30/80% 3000	3000+30/70% 3000
1000+30/70% 2000	1500+40/70% 3000	3000+40/70% 1500
1000+30/80% 1500	1500+40/80% 2000	5000+30/70% 3000
1500+20/80% 2000	2000+20/80% 1500	5000+40/80% 1500
1500+30/70% 3000	2000+30/70% 2000

Mandated Plans

Basic	Catastrophic
Standard	Conversion

Optional Benefits

Prescription Drug Plans

Preferred:

Tiered 10/20/40

Tiered 15/20%/50%

Tiered 15/30/50

SmartHealth for Business:

10/30%/50% 5000	10/250+30%/50% 5000
HSA 10/50%/50%	10/250+50%/50%

Traditional:

Tiered 7/25/50	Tiered 7/250+30%/50% 2500
Tiered 7/35/50	Tiered 7/500+30%/50% 2500
Tiered 10/35/50	Tiered 7/750+30%/50% 2500
Tiered 15/35/50	Tiered 7/1000+30%/50% 2500
	Tiered 7/5000+30%/50% 2500

Dental Plans

Preventive $25/$1500	Preventive $50/$1000	Comp $50/$1500
Preventive $25/$1000	Comp $25/$1500	Comp $50/$1000
Preventive $50/$1500	Comp $25/$1000	Orthodontia

Vision Plans

Vision Plus	Vision 10/200	Vision 10/100
Vision Exam Only

Alternative Care and Chiropractic Care Plans

SmartHealth for Business Alternative Care 30-500

SmartHealth for Business Alternative Care 40-500

Traditional Chiro

Life and Disability Plans

$10,000	$10,000 with dependent option
$20,000	$20,000 with dependent option
$30,000	$30,000 with dependent option
$40,000	$40,000 with dependent option
$50,000	$50,000 with dependent option

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Idaho plan summaries en Español
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Oregon plan summaries en Español
For group-specific benefit summaries, contact our Boise office at (208) 342-3709 or (888) 492-2875

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Last updated 9/1/2010