2016 Montana Large Group Plans

The information on this page is for small group plans beginning January 1, 2016. Small groups in Montana are employers with one to 51+ employees.

 Medical Plans


 

Plan

Deductible*

OOP*

Co-insurance

HSA-eligible?

SBCs and Handbooks
by Network
Summaries
by Network
   Balance 500+20_20
$500
$5,000
20%
No
PSN / SHN
 Balance 750+20_20
$750
$5,000
20%
No
PSN / SHN
PSN / SHN
 Balance 1000+20_20
$1,000
$5,000
20%
No
PSN / SHN
PSN / SHN
 Balance 1500+20_20
$1,500
$5,500
20%
No
PSN / SHN
PSN / SHN
 Balance 2000+20_30
$2,000
$6,000
30%
No
PSN / SHN
PSN / SHN
 Balance 2500+20_30
$2,500
$6,000
30%
No
PSN / SHN
PSN / SHN
 Balance 3000+20_30
$3,000
$6,000
30%
No
PSN / SHN
PSN / SHN
 Balance 4000+20_30
$4,000
$6,000
30%
No
PSN / SHN
 PSN / SHN
   Value 3000 50+Rx
$3,000
$6,350
50%
Yes
PSN / SHN
PSN / SHN
 Value 3000+Rx
$3,000
$3,000
0%
Yes
PSN / SHN
PSN / SHN
 Value 4000+Rx
$4,000
$4,000
0%
Yes
PSN / SHN
PSN / SHN
 Value 5000+Rx
$5,000
$5,000
0%
Yes
PSN / SHN
PSN / SHN

*Deductible and out-of-pocket limit amounts shown below are the costs for individuals. Amounts for families are twice the individual amounts.

Dental Plans


   Dental Choice Plus 0-20-50 25-1000 Dental Choice Plus 0-20-50 50-1000
 Dental Choice Plus 0-20-50 25-1500 Dental Choice Plus 0-20-50 50-1500 
 Dental Choice Plus 0-20-50 25-2000 Dental Choice Plus 0-20-50 50-2000
   Kids Dental Choice 0-20-50 Kids Dental Choice 20-40-50
   Ortho 1000 Ortho 1500 

Voluntary Dental Option Plans

Our Voluntary Dental option is available to businesses with ten or more enrolled employees. For information and requirements, please see our Voluntary Dental flier.

  Dental Choice 0-20-50 25-1500 Voluntary Dental Choice 0-20-50 50-1000 Voluntary
Dental Choice 0-20-50 50-1500 Voluntary Dental Choice 0-20-50 50-2000 Voluntary

Pharmacy Plans


   MT 3000D MDL MT 50P MDL
 MT 4000D MDL MT 10-50P-50P MDL
 MT 5000D MDL MT 10-35-60 MDL
  MT 10-35-60 150D MDL

Chiropractic Manipulation and Acupuncture


   Summary

Vision Plans


    Vision 10/150 Vision Plus
 Vision 10/300 Vision Exam Only

Brochure and Forms


Brochures

Forms

Visit our Montana Forms and Materials page for more sales materials.

Network Availability


All network plans are available direct with PacificSource.

PacificSource Network (PSN)

 

 

 

  The PacificSource Network (PSN) is our PPO network. It gives members the freedom to choose any participating provider any time. Members can also see providers outside of this network, but they'll pay a little more (nonparticipating benefit costs). Because members have more freedom to choose any participating doctor, PSN plans will have slightly higher premiums.

 

 

 

SmartHealth Network (SHN)

 

 

 

 

SmartHealth is a coordinated care network (CCN). A CCN is a network where members choose a primary care provider (PCP) who will work with them to help them meet their health and wellness goals. Should a member need to see a specialist, their PCP will work with them and their specialist to coordinate the care they receive. Providers and facilities in SHN are connected through common care goals and work together to provide the best possible care at the lowest possible cost for our members. Premiums for SHN plans are typically lower than those for our PSN plans.