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.

Sample summary of benefits and coverage (SBC) documents coming soon.

If you would like an older summary, please contact your Sales Representative.

Preferred Plan Limitations for plans effective August 1, 2012

SmartHealth Plan Limitations for plans effective August 1, 2012

Preventive Care Limits for Idaho Group Plans - Preferred
Preventive Care Limits for Idaho Group Plans - SmartHealth

Small Group Plans

Preferred CoDeduct Plans

Effective August 1, 2012:

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

Preferred Deductible and Percentage Plans

Effective August 1, 2012:

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

Preferred HSA Plans

Effective August 1, 2012:

Plans with Rx Coverage	Plans without Rx Coverage
80+1500	80+1500
80+2000	80+2000
80+3000	80+3000
100+5000	100-5000

SmartHealth for Business Plans

Effective August 1, 2012:

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

Large Group Plans

Preferred CoDeduct Plans

Effective August 1, 2012:

Plans with Mental Health and Chemical Dependency Benefits

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

Effective August 1, 2012:

Plans without Mental Health and Chemical Dependency Benefits

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

Preferred Deductible and Percentage Plans

Effective August 1, 2012:

Plans with Mental Health and Chemical Dependency Benefits

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

Effective August 1, 2012:

Plans without Mental Health and Chemical Dependency Benefits

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

Preferred HSA Plans

Effective August 1, 2012:

Plans with Mental Health and Chemical Dependency Benefits

Plans with Rx Coverage	Plans without Rx Coverage
80+1500	80+1500
80+2000	80+2000
80+3000	80+3000
100+5000	100-5000

Effective August 1, 2012:

Plans without Mental Health and Chemical Dependency Benefits

Plans with Rx Coverage	Plans without Rx Coverage
80+1500	80+1500
80+2000	80+2000
80+3000	80+3000
100+5000	100-5000

SmartHealth for Business Plans

Effective August 1, 2012:

Plans with Mental Health and Chemical Dependency Benefits:

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

Plans without Mental Health and Chemical Dependency Benefits:

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

Mandated Plans

Basic	Catastrophic
Standard

Optional Benefits

Prescription Drug Plans

Effective August 1, 2012:

Preferred:

Tiered 10/20/40	Tiered 15/20%/50%	Tiered 15/30/50
HSA 80%	HSA 100%

SmartHealth for Business:

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

Dental Plans

Indemnity Plans	Dental Advantage Premier (PPO)	Dental Advantage (PPO)
Preventive $25/$1,000	80/80/80/50 25/1000	80/80/50/50 25/1000
Preventive $50/$1,000	80/80/80/50 25/1500	80/80/50/50 25/1500
Preventive $25/$1,500	80/80/80/50 25/2000	80/80/50/50 25/2000
Preventive $50/$1,500	80/80/80/50 50/1000	80/80/50/50 50/1000
Comp $25/$1,000	80/80/80/50 50/1500	80/80/50/50 50/1500
Comp $50/$1,000	80/80/80/50 50/2000	80/80/50/50 50/2000
Comp $25/$1,500	100/80/80/50 25/1000	100/80/50/50 25/1000
Comp $50/$1,500	100/80/80/50 25/1500	100/80/50/50 25/1500
Orthodontia	100/80/80/50 25/2000	100/80/50/50 25/2000
	100/80/80/50 50/1000	100/80/50/50 50/1000
	100/80/80/50 50/1500	100/80/50/50 50/1500
	100/80/80/50 50/2000	100/80/50/50 50/2000

Diamond Available on a stand-alone basis for groups with 2 to 9 enrolled employees

Dental Coverage Options (For small groups with 2-50 eligible employees)

Preventive

Preventive Basic

Vision Plans

Vision Plus	Vision 200	Vision 100
Vision Exam Only

Alternative Care and Chiropractic Care Plans

Alt/Chiro $900 max

SmartHealth for Business Alternative Care 30-500

SmartHealth for Business Alternative Care 40-500

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

Other Optional Benefits

Additional Accident Benefit

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For group-specific benefit summaries, contact our Boise office at (208) 342-3709 or (888) 492-2875.

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Last updated 4/5/2013

Sample Plan Summaries for Idaho

Small Group Plans

Preferred CoDeduct Plans

Preferred Deductible and Percentage Plans

Preferred HSA Plans

SmartHealth for Business Plans

Large Group Plans

Preferred CoDeduct Plans

Preferred Deductible and Percentage Plans

Preferred HSA Plans

SmartHealth for Business Plans

Mandated Plans

Optional Benefits

Prescription Drug Plans

Dental Plans

Indemnity Plans

Dental Advantage Premier (PPO)

Dental Advantage (PPO)

Vision Plans

Alternative Care and Chiropractic Care Plans

Life and Disability Plans

Other Optional Benefits

InTouch Login

Looking for more plan summaries?

Looking for Individual Information?