Health plans to help you live well and smile more.

Transcription

1 Health plans to help you live well and smile more Health Plans for Idaho Individuals and Families

2 We re in your corner for great healthcare. You work hard every day to take care of yourself and your family. It s worth it, because when you feel well, you re able to enjoy everything else a little bit more. And we know that good health and feeling well are a lot easier when you have people who care about you in your corner. For more than 80 years, we ve dedicated ourselves to providing healthcare coverage to the people in our communities people like you and your family. We work with you and providers to help you receive the quality healthcare you need. When it comes to getting that care, we ve got you covered. 2

3 Our Networks A network is your healthcare team. A network is a set of doctors, hospitals, and other providers who care for your health. When you receive care from providers in your health plan s network, you typically pay less than if you see providers outside your plan s network. 3

4 Our Networks We offer plans in two networks. Access more providers with our PacificSource Network. The PacificSource Network (PSN) includes the broadest access to in-network providers and facilities, such as hospitals and urgent care centers. Plans on the PacificSource Network will typically cost more because you ll have more providers to choose from. Our Networks Lower your costs with our BrightPath Network. The BrightPath Network is designed to give you a coordinatedcare experience through select provider groups and facilities. Your primary care doctor, specialists, and hospitals work together as a team. This focus on communication and collaboration allows for high-quality, streamlined care at the lowest possible costs. PacificSource Network (PSN) If you live in one of the following counties, you can choose plans on the PacificSource Network: Bannock Bear Lake Benewah Bingham Bonner Bonneville Boundary Butte Caribou Clark Clearwater Custer Franklin Fremont Idaho Jefferson Kootenai Latah Lemhi Lewis Madison Nez Perce Oneida Power Shoshone Teton BrightPath Network This network includes coverage with St. Luke s providers and facilities, as well as other local healthcare providers. If you live in one of the following counties, you can choose BrightIdea plans on the BrightPath Network: Ada Adams Blaine Boise Camas Canyon Cassia Elmore Gem Gooding Jerome Lincoln Minidoka Owyhee Payette Twin Falls Valley Washington 4

5 Get care nationwide with our travel networks. Our network service area includes providers in Idaho, Montana, and Oregon. Beyond that, you ll have access to in-network providers, nationwide. We partner with the First Choice Health TM Network for Washington and Alaska and with the First Health Network for all other states. Find a provider in our online directory. To get healthcare at the lowest cost, you ll need to go to providers in your plan s network. You can use our Provider Directory at PacificSource.com/ find-a-provider to look up in-network doctors and facilities. Our Networks 5

6 Medical Plans Health plans to help you live well. Chances are, you want a quality health plan that makes getting healthcare as easy and affordable as possible. We can help with that. No matter which plan you choose, your preventive care is covered. This includes things like routine physicals and immunizations. Plus, if you choose an HSA plan, you can set up a health savings account to help you save for future healthcare expenses. 6

7 Catastrophic Available only in the BrightPath network Only available for people under 30 or people of any age with a hardship exemption or affordability exemption Medical Plans Calendar Year Costs Deductible This is the amount you must pay before the plan pays for covered services. Out-of-pocket limit This is the most you will pay for covered services in a calendar year. In-network Individual: $7,350 Family: $14,700 Individual: $7,350 Family: $14,700 Out-of-network Individual: $10,000 Family: $20,000 Individual: $100,000 Family: $200,000 Commonly Used Benefits Office visits Primary (including telemedicine); services performed during an office visit may be billed separately. Visits 1-3 deductible waived. Visits 4+ after deductible, covered in full. After deductible, 50% Specialist visits After deductible, covered in full After deductible, 50% Chiropractic manipulation and acupuncture After deductible, covered in full After deductible, 50% Lab and x-ray services After deductible, covered in full After deductible, 50% Hospitalization and outpatient care After deductible, covered in full After deductible, 50% Urgent care After deductible, covered in full After deductible, 50% Emergency services Accident benefit Prescription drugs After deductible, covered in full After deductible, Emergency: covered in full Nonemergency: 50% Within 90 days of an accident (not at work), the first $500 of covered services is paid in full Preventive: covered in full All tiers: after deductible, covered in full Preventive: after deductible, 90% All tiers: after deductible, 90% Vision Benefits Pediatric routine eye exam After deductible, covered in full After deductible, 50% Pediatric vision hardware After deductible, covered in full After deductible, 50% Adult routine eye exam Adult vision hardware Not covered Not covered 7

8 Bronze HSA 6550 Available only in the BrightPath network Medical Plans Calendar Year Costs Deductible This is the amount you must pay before the plan pays for covered services. Out-of-pocket limit This is the most you will pay for covered services in a calendar year. In-network Individual: $6,550 Family: $13,100 Individual: $6,550 Family: $13,100 Out-of-network Individual: $10,000 Family: $20,000 Individual: $100,000 Family: $200,000 Commonly Used Benefits Office visits Primary (including telemedicine); services performed during an office visit may be billed separately. After deductible, covered in full After deductible, 50% Specialist visits After deductible, covered in full After deductible, 50% Chiropractic manipulation and acupuncture After deductible, covered in full After deductible, 50% Lab and x-ray services After deductible, covered in full After deductible, 50% Hospitalization and outpatient care After deductible, covered in full After deductible, 50% Urgent care After deductible, covered in full After deductible, 50% Emergency services Accident benefit Prescription drugs After deductible, covered in full After deductible, Emergency: covered in full Nonemergency: 50% Within 90 days of an accident (not at work), the first $500 of covered services is paid in full Preventive: covered in full All tiers: after deductible, covered in full Preventive: after deductible, 90% All tiers: after deductible, 90% Vision Benefits Pediatric routine eye exam Covered in full Covered in full up to $40 Pediatric vision hardware Adult routine eye exam Adult vision hardware Covered in full up to $150, then subject to medical deductible Not covered Not covered 8

9 Silver HSA 3000 Medical Plans Calendar Year Costs Deductible This is the amount you must pay before the plan pays for covered services. Out-of-pocket limit This is the most you will pay for covered services in a calendar year. In-network Individual: $3,000 Family: $6,000 Individual: $5,000 Family: $10,000 Out-of-network Individual: $10,000 Family: $20,000 Individual: $100,000 Family: $200,000 Commonly Used Benefits Office visits Primary (including telemedicine); services performed during an office visit may be billed separately. After deductible, 25% After deductible, 50% Specialist visits After deductible, 25% After deductible, 50% Chiropractic manipulation and acupuncture After deductible, 25% After deductible, 50% Lab and x-ray services After deductible, 25% After deductible, 50% Hospitalization and outpatient care After deductible, 25% After deductible, 50% Urgent care After deductible, 25% After deductible, 50% Emergency services After deductible, 25% Accident benefit Prescription drugs Vision Benefits After deductible, Emergency: 25% Nonemergency: 50% Within 90 days of an accident (not at work), the first $500 of covered services is paid in full Preventive: covered in full All tiers: after deductible, 25% Preventive: after deductible, 90% All tiers: after deductible, 90% Pediatric routine eye exam Covered in full Covered in full up to $40 Pediatric vision hardware Adult routine eye exam Adult vision hardware Covered in full up to $150, then then after medical deductible, 25% Not covered Not covered 9

10 Gold 1500 Medical Plans Calendar Year Costs Deductible This is the amount you must pay before the plan pays for covered services. Out-of-pocket limit This is the most you will pay for covered services in a calendar year. In-network Individual: $1,500 Family: $3,000 Individual: $5,000 Family: $10,000 Out-of-network Individual: $10,000 Family: $20,000 Individual: $100,000 Family: $200,000 Commonly Used Benefits Office visits Primary (including telemedicine); services performed during an office visit may be billed separately. After deductible, 10% After deductible, 50% Specialist visits After deductible, 10% After deductible, 50% Chiropractic manipulation and acupuncture After deductible, 10% After deductible, 50% Lab and x-ray services After deductible, 10% After deductible, 50% Hospitalization and outpatient care After deductible, 10% After deductible, 50% Urgent care After deductible, 10% After deductible, 50% Emergency services After deductible, 10% Accident benefit Prescription drugs Vision Benefits After deductible, Emergency: 10% Nonemergency: 50% Within 90 days of an accident (not at work), the first $500 of covered services is paid in full Preventive: covered in full All tiers: after deductible, 10% Preventive: after deductible, 90% All tiers: after deductible, 90% Pediatric routine eye exam Covered in full Covered in full up to $40 Pediatric vision hardware Adult routine eye exam Adult vision hardware Covered in full up to $150, then after medical deductible, 10% Not covered Not covered 10

11 Medical Plans Save money for future healthcare expenses. If you want to set aside money for future healthcare expenses, you ll want to consider our HSA-qualified plans. With these plans, you can open a health savings account (HSA) and deposit money into it specifically to pay for healthcare costs, such as your deductible and co-insurance. You can even use this money for medical services that aren t covered by your plan. Anyone can contribute money to your HSA. Our HSA-qualified plans include HSA in the plan name. 11

12 What s not covered? Below is a complete list of services and treatments that are not covered under our medical plans. A full explanation of benefits, including limitations and exclusions, will be provided in the policy. Please note: Only the language of the actual policy is legally binding. Abdominoplasty for any indication Academic skills training Acute care, rehabilitative, diagnostic testing, except as specified as a covered service in this policy. Any amounts in excess of the allowable fee for a given service or supply Biofeedback (other than as specifically noted under the Covered Expenses Other Covered Services, Supplies, and Treatment section of the policy) Charges for phone consultations, missed appointments, get-acquainted visits, completion of claim forms, or reports PacificSource needs to process claims Charges over the usual, customary, and reasonable fee (UCR) Any amount in excess of the UCR for a given service or supply Charges that are the responsibility of a third party who may have caused the illness, injury, or disease or other insurers covering the incident (such as workers compensation insurers, automobile insurers, and general liability insurers) Chelation therapy Computer or electronic equipment for monitoring asthmatic, diabetic, or similar medical conditions or related data Cosmetic/reconstructive services and supplies Except as specified in the Covered Expenses Other Covered Services, Supplies, and Treatments section of the policy Court-ordered sex offender treatment programs Court-ordered screening interviews or drug or alcohol treatment programs Day care or custodial care Care and related services designed essentially to assist a person in maintaining activities of daily living Dental examinations and treatment Drugs and biologicals that can be self-administered (including injectables), other than those provided in a hospital emergency room or other institutional setting, or as outpatient chemotherapy and dialysis, which are covered Covered drugs and biologicals that can be selfadministered are otherwise available under the pharmacy benefit, subject to plan requirements Drugs or medications not prescribed for inborn errors of metabolism, diabetic insulin, or autism spectrum disorder that can be self-administered (including prescription drugs, injectable drugs, and biologicals), unless given during a visit for outpatient chemotherapy or dialysis or during a medically necessary hospital, emergency room, or other institutional stay Durable medical equipment available over the counter and/or without a prescription Educational or correctional services or sheltered living provided by a school or halfway house, except outpatient services received while temporarily living in a shelter Elective abortions, except if a consulting physician recommends that an abortion is necessary to save the life of the mother, or the pregnancy is a result of rape (as defined by state) or incest (as determined by the courts) Equine/animal therapy Equipment commonly used for nonmedical purposes or marketed to the general public Equipment used primarily in athletic or recreational activities Experimental or investigational procedures Eye examinations (routine) for members age 19 and older, unless included in plan design Eye exercises, therapy, and procedures Eye glasses/contact lenses for members age 19 and older, unless included in plan design Family planning Services and supplies for artificial insemination, in vitro fertilization, diagnosis and treatment of infertility, erectile dysfunction, sexual dysfunction, or surgery to reverse voluntary sterilization Fitness or exercise programs and health or fitness club memberships Foot care (routine) Services and supplies for corns and calluses of the feet, conditions of the toenails other than infection, hypertrophy or hyperplasia of the skin of the feet, and other routine foot care, except in the case of patients being treated for diabetes mellitus Hearing aids including the fitting, provision, or replacement of hearing aids Homeopathic medicines or homeopathic supplies Medical Plans 12

13 Hypnotherapy, except in the treatment of mental or nervous conditions Immunizations when recommended for, or in anticipation of, exposure through travel or work Inpatient or outpatient custodial care; inpatient or outpatient services consisting mainly of educational therapy, behavioral modification, self-care or self-help training, except as specified as a covered service in this policy Instructional or educational programs, except diabetes self-management programs, unless medically necessary Jaw Procedures, services, and supplies Jaw surgery Learning disorders Maintenance supplies and equipment not unique to medical care Marital/partner counseling Massage or massage therapy, even as part of a physical therapy program Mattresses and mattress pads are only covered when medically necessary to heal pressure sores Mental health treatments for conditions defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) that are not attributable to a mental health disorder or disease Modifications to vehicles or structures to prevent, treat, or accommodate a medical condition Motion analysis Naturopathic treatment and supplies Nicotine related disorders, other than those covered through tobacco cessation program services Nondependent newborn For the purpose of this plan, a newborn will not be considered an eligible dependent if the member has entered into a contract or other understanding to which the newborn is being relinquished to the intended parents at birth Obesity or weight control Surgery or other related services or supplies provided for weight control or obesity (including all categories of obesity), when not medically necessary Orthognathic surgery Services and supplies to augment or reduce the upper or lower jaw, except as specified under Professional Services in the Covered Expenses section of the policy Orthopedic shoes, diabetic shoes, and shoe modifications Osteopathic manipulation, except for treatment of disorders of the musculoskeletal system Over-the-counter medications or nonprescription drugs Panniculectomy, for any indication Paraphilias Personal items, such as telephones, televisions, and guest meals during a stay at a hospital or other inpatient facility Physical or eye examinations required for administrative purposes, such as participation in athletics, admission to school, or by an employer Private nursing service Programs that teach a person to use medical equipment, care for family members, or self administer drugs or nutrition (except for diabetic education benefit) Psychoanalysis or psychotherapy received as part of an educational or training program, regardless of diagnosis or symptoms that may be present Recreation therapy Outpatient Rehabilitation Functional capacity evaluations, work hardening programs, vocational rehabilitation, community reintegration services, and driving evaluations and training programs. Replacement costs for worn or damaged durable medical equipment that would otherwise be replaceable without charges under warranty or other agreement Scheduled and/or nonemergent medical care outside of the United States Screening tests Services and supplies, including imaging and screening exams performed for the sole purpose of screening and not associated with specific diagnoses and/or signs and symptoms of disease or of abnormalities on prior testing Self-help or training programs Sensory integration training Services for which no charge is normally made in the absence of insurance Services of providers who are not eligible for reimbursement under the plan Services or supplies provided by, or payable under, any plan or program established by a domestic or foreign government or political subdivision, unless such exclusion is prohibited by law Services or supplies with no charge, or for which the member is not legally required to pay, or for which a provider or facility is not licensed to provide even though the service Medical Plans 13

14 or supply may otherwise be eligible. This exclusion includes any service provided by the member, or any licensed medical professional that is directly related to the member by blood or marriage Services required by state law as a condition of maintaining a valid driver s license or commercial driver s license Services, supplies, and equipment not involved in diagnosis or treatment but provided primarily for the comfort, convenience, intended to alter the physical environment, or education of a patient Sexual disorders Services or supplies for the treatment of sexual dysfunction or inadequacy, unless medically necessary to treat a mental health issue and diagnosis Social skill training Temporomandibular joint (TMJ) Related services, or treatment for associated myofascial pain, including physical or orofacial therapy Training or self-help health or instruction Transplants Any services, treatment or supplies for the transplantation of bone marrow or peripheral blood stem cells or tissue, except as expressly provided under the provisions of this plan for covered transplantation expenses Treatment after insurance ends Services or supplies a member receives after the member s coverage under this plan ends Treatment not medically necessary Treatment of any illness, injury, or disease arising out of an illegal act or occupation or participation in a felony Treatment of any work-related illness, injury, or disease, unless you are the owner or partner, and are otherwise exempt from, and not covered by, state or federal workers compensation insurance. This includes illness, injury or disease caused by any for-profit activity whether through employment or self-employment Treatment of intellectual disabilities, as defined in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) Treatment prior to enrollment Unwilling to release information Charges for services or supplies for which a member is unwilling to release medical or eligibility information necessary to determine the benefits payable under the plan Vocational rehabilitation, functional capacity evaluations, work hardening programs, community reintegration services, and driving evaluations and training programs, except as medically necessary in the restoration or improvement of speech following a traumatic brain injury or for a child 18 years or younger diagnosed with a pervasive development disorder War-related conditions The treatment of any condition caused by or arising out ofany act of war, or any war declared or undeclared or while in the service of the armed forces Medical Plans 14

15 Renewability of Policy Individual policies shall be renewable with respect to the Insured, at the option of the Policyholder, except in any of the following cases: nonpayment of the required premiums; fraud or intentional misrepresentation of material fact by the Insured or his representatives; the individual s residence changes to one which is outside the established geographic Service Area; if this Policy is made available to the individual through one (1) or more associations, and the membership of the employer in the association ceases; and/or PacificSource Health Plans elects to not renew all of its policies delivered or issued for delivery to individuals in the state of Idaho. Pre-existing Condition A Pre-existing Condition means the existence of a condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment within a six (6) month period immediately preceding the Effective Date of coverage; or a pregnancy existing on the Effective Date of coverage. The Pre-existing Condition exclusion does not apply to any insured members or their dependents under the individual policies contained in this sales literature. Disclosure of Premium Practices and Guarantees a) How Premiums Are Set Your premium is determined by the benefits you selected, your geographic location, and the age of the individuals covered on your policy. Any renewal premium increase is due to changes in age and any increase approved by the Department of Insurance. b) Premium Guarantee We guarantee initial premium until your next renewal date. Your premium may change if you change your benefits at renewal. Medical Plans 15

16 Dental Plans Our dental plans give you more to smile about. Good dental health and regular preventive care are important to your overall well-being. That s why we offer dental plans that you can group with your health plan. Our dental plans are also available as stand-alone plans, even if you don t choose one of our medical plans. 16

17 Choose a plan on our Dental Advantage Network. With Dental Advantage plans, you ll have access to a robust network of more than 1,800 dental providers in Idaho, Oregon, and Washington. It s important that you see Dental Advantage Network dentists. Otherwise, you ll end up paying more out of pocket for your dental care. You can find dentists who are in the Dental Advantage Network at PacificSource.com/find-a-dentist. Dental Plans 17

18 Dental Advantage Dental Plans Dental Advantage 0/20/50 Network A group of dental providers you must choose from in order for the plan to pay as shown here. Annual maximum benefit The most we will pay in a calendar year for adults 19 and older. Annual deductible The amount you ll have to pay in a calendar year before the plan pays for covered Class II and Class III services. See page 19. Pediatric out-of-pocket limit The most you ll pay in a calendar year for enrolled kids through age 18. Co-insurance Your share of costs, after your deductible has been paid (if applicable). See page 19 for more about Class I, II, and III services. Adult waiting period There is no waiting period for members through age 18. Dental Advantage $1,000 None Child: $350 Two or more children: $700 Class I: 0% Class II: 20% Class III: 50% Class II: 6 months Class III: 12 months Kids Dental Advantage 0/20/50 (for members through age 18) Network A group of dental providers you must choose from in order for the plan to pay as shown here. Annual maximum benefit The most we will pay in a calendar year for adults 19 and older. Annual deductible The amount you ll have to pay in a calendar year before the plan pays for covered Class II and Class III services. See page 19. Pediatric out-of-pocket limit The most you ll pay in a calendar year for enrolled kids through age 18. Co-insurance Your share of costs, after your deductible has been paid (if applicable). See page 19 for more about Class I, II, and III services. Adult waiting period There is no waiting period for members through age 18. Dental Advantage N/A None Child: $350 Two or more children: $700 Class I: 0% Class II: 20% Class III: 50% N/A 18

19 Dental Plans What s covered? Here is a brief list of services and treatments most commonly asked about. Go to PacificSource.com/idaho/individual-dental-2018 to get all the details. Class I: Preventive Services Exams and x-rays Dental cleanings (prophylaxis or periodontal maintenance) Fluoride applications Sealant on bicuspids and permanent molars (kids through age 18 only) Brush biopsies Class II: Basic Services Simple extractions Periodontal scaling and root planning and/or curettage Full mouth debridement Fillings Class III: Major Services Complicated and oral surgery Endodontic (pupal therapy and root canal therapy) Periodontal surgery when preauthorized Full, immediate, or overdentures Crowns and bridges Child orthodontia (medically necessary only; all plans; kids through age18) 19

20 What s not covered? Below is a complete list of services and treatments that are not covered under our dental plans. A full explanation of benefits, including limitations and exclusions, will be provided in the policy. Please note: Only the language of the actual policy is legally binding. Aesthetic dental procedures Antimicrobial agents Athletic activities Any injuries sustained while competing or practicing for a professional athletic contest Athletic mouth guards for enrolled individuals age 19 and older Biopsies or histopathologic exams Charges for broken appointments Collection of cultures and specimens for enrolled individuals age 19 and older Comprehensive periodontal exams for enrolled individuals age 19 and older Connector bar or stress breaker Core build-ups are not covered unless used to restore a tooth that has been treated endodontically (root canal) for enrolled individuals age 19 and older Cosmetic/reconstructive services and supplies Denture replacement made necessary by loss, theft, or breakage Diagnostic casts Diagnostic casts (study models) and occlusal appliances for enrolled individuals age 19 and older Diagnostic casts Gnathological recordings, occlusal equilibration procedures, or similar procedures Drugs and medications that are prescribed drugs, and take-home medicine or supplies distributed by a provider for any member Educational programs Instructions and/or training in plaque control and oral hygiene for individuals age 19 and older Experimental or investigational procedures Fractures of the maxilla and mandible General anesthesia, except when administered by a dentist in connection with oral surgery in his/her office Gingivectomy, gingivoplasty, or crown lengthening in conjunction with crown preparation or bridge services done on the same date of service Hospital charges or additional fees charged by the dentist for hospital treatment for enrolled individuals age 19 and older Hypnosis Indirect pulp caps are to be included in the restoration process, and are not a separate covered benefit Infection control Intra and extra coronal splinting Orthodontic services Repair or replacement of orthodontic appliances furnished under the plan Orthodontic services Treatment of misalignment of teeth and/ or jaws, or any ancillary services expressly performed because of orthodontic treatment, except as provided for medically necessary treatment when treatment began prior to turning age 19 and was not completed prior to turning age 19 Orthognathic surgery Periodontal probing, charting, and re-evaluations Photographic images Pin retention in addition to restoration for enrolled individuals age 19 and older Precision attachments Pulpotomies on permanent teeth for members age 19 and older Removal of clinically serviceable amalgam restorations to be replaced by other materials free of mercury, except with proof of allergy to mercury Services covered by the member s medical plan Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth Services or supplies for which no charge is made, which you are not legally required to pay, or which a provider or facility is not licensed to provide, even though the service or supply may otherwise be eligible Services or supplies provided outside of the United States, except in cases of emergency Sinus lift grafts to prepare sinus site for implants Stress-breaking or habit-breaking appliances Temporomandibular joint (TMJ) Services or supplies for treatment of any disturbance of the temporomandibular joint Third party liability, motor vehicle liability, motor vehicle insurance coverage, or workers compensation Tooth transplantation Treatment after insurance ends Treatment not dentally necessary according to acceptable dental practice, or treatment not likely to have a reasonably favorable prognosis Treatment of any illness, injury, or disease resulting from an illegal occupation or attempted felony, or treatment received while in the custody of any law enforcement authority Treatment prior to enrollment Unwilling to release information War-related conditions Dental Plans 20

21 Tools and Programs Tools and programs to help you take charge of your health. We know that health and dental plan benefits and what they cost you are incredibly important. But it s also important to have the tools and resources needed to take charge of your health, without paying extra. With our free health-and-benefit tools and wellness programs, you ll have support to help you live healthy and make the most of your health plan s benefits. 21

22 Free Tools and Programs Access benefits 24/7 with InTouch. Through InTouch, our secure website for members, you can check out your claims, preauthorization status, progress toward your plan s deductible, and more. You can log into or sign up for InTouch at PacificSource.com. See if a service requires preauthorization. Sometimes, you ll need a medical service, procedure, or prescription that must be preauthorized approved in advance before your health plan will pay. Our preauthorization lists outline common instances when preauthorization is required. Some plans may not cover all items on the lists. Visit PacificSource.com/member/preauthorization for more information. See how a drug is covered. We offer prescription drug lists to providers so that they have the information they need to keep drug costs low for you. To help with that, we substitute generic drugs in place of brand name drugs whenever we can. In most cases, we also offer preventive drugs at no cost. For more information, visit PacificSource.com/drug-list, and select Idaho Drug List (IDL). Wait, there s more! You will also have free access to: mypacificsource mobile app (PacificSource.com/mobile) CaféWell health and wellness portal (PacificSource.com/cafewell) Tools and Programs 22

23 Tools and Programs More extras for your health. You can also enjoy these extra benefits and wellness programs: Active&Fit gym membership program Teladoc on-demand virtual medical care 24-Hour NurseLine Assist America Global Emergency Services Case management services Condition Support Program Hospital-based health and wellness class reimbursement Prenatal Program Quit For Life tobacco cessation Weight management programs You ll find details about these programs and services at PacificSource.com/extras. 23

24 Ready to Enroll? Choose a network. See page four to find out whether the PacificSource Network (PSN) or BrightPath Network is available where you live. Ready to Enroll? Choose a plan. Deductible and out-of-pocket limit amounts shown below are the costs for individuals. Amounts for families are twice the individual amounts. If you receive services from providers who are not in your plan s network, then your deductible and out-of-pocket limit will be higher than the amounts listed in the chart below. Plan Catastrophic Only available for people under 30 or people of any age with a hardship exemption or affordability exemption. Deductible Out-ofpocket limit Cost share for office visits after deductible Co-insurance after deductible $7,350 $7,350 Covered in full t Covered in full Bronze HSA 6550 $6,550 $6,550 Covered in full Covered in full Silver HSA 3000 $3,000 $5,000 25% 25% Gold 1500 $1,500 $5,000 10% 10% Available only in BrightPath networks. t The first three office visits combined are paid at 100 percent after any applicable co-pay. After that, office visits are subject to deductible and co-insurance. Enroll. Enroll online: To enroll online directly with PacificSource: 1. Go to PacificSource.com/idaho/individual-plan-details Click Compare Rates and Apply Online. 3. Choose PacificSource >. 4. Follow the on-screen instructions to complete and submit your enrollment application. If you re eligible for financial assistance, you ll need to enroll through Your Health Idaho, Idaho s Health Insurance Marketplace. Visit YourHealthIdaho.org to find out if you re eligible. Enroll by , fax, or mail: Complete a paper enrollment form and submit it to us at: idahoindividual@pacificsource.com Fax: (208) Mail: PacificSource Health Plans Attn: Individual Department PO Box 7068 Springfield, OR

25 Contact us. Phone: (855) Web: PacificSource.com/idaho/individual-plan-details-2018 Your privacy is important to us. To learn more about how we protect our members personal information, check out our privacy policy at PacificSource.com/privacy. IFP1_1217