Sample Plan Summaries for Montana

The sample summaries and plan limitations 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.

Additional sample summaries and plan limitations will be posted as soon as they are approved.

Group Medical Plans

PPO Plans

Benefit Limitations and Exclusions for plans effective December 1, 2011.

500+20/80% 2000	3000+20/50% 4000	70%+2000
1000+20/70% 2000	3000+20/70% 2000	70%+3000
1000+20/80% 2000	3000+20/70% 4000	70%+5000
1500+20/70% 2000	3000+20/80% 2000	50%+3000
2000+20/70% 2000	5000+20/50% 4000	50%+5000
2000+20/70% 4000	5000+20/70% 2000
2000+20/80% 2000	5000+20/70% 4000
2500+20/70% 2000	5000+20/80% 2000
2500+20/70% 4000
2500+20/80% 2000

HSA-Qualified Plans

Benefit Limitations and Exclusions for plans effective December 1, 2011.

Plans with Rx Coverage	Plans without Rx Coverage
100+3000 Rx	100+3000
100+5000 Rx	100+5000
100+6050 Rx	100+6050

Optional Benefits

Prescription Drug Plans

Tiered Incentive 4/10/35/60
Tiered 10/35/60	Tiered 10/35/60%
Tiered 10/50/75	Tiered 10/150+35/60

Dental Indemnity: Healthy Smiles Plans

25/1000	50/1000
25/1500	50/1500
25/2000	50/2000
Orthodontia

Vision Plans

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

Alternative Care

$500 Alternative Care	$1,000 Alternative Care
$1,500 Alternative Care	$2,000 Alternative Care (large groups only)

Other Optional Benefits

Additional Accident Benefit

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Last updated 5/15/2012