SmartHealth Balance Silver 2500

PacificSource Health Plans

Plan Network

To see how this plan's network compares to others in your area, we will need your zip code.

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Plan Coverage
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Doctor Visits

Primary Care
First 4 visits free
$20 copay
Specialist
$50 copay
Preventative Care
0

Prescriptions

Generic Drugs
$10 copay
Brand Drugs
$50 copay
Brand Drugs (Non-Preferred)
$75 copay
Specialty Drugs
$250 copay

Hospital

Emergency Room
30% Coinsurance after deductible, $250 Copay after deductible
Ambulance
30% Coinsurance after deductible
Hospital Stay (Facility)
30% Coinsurance after deductible
Hospital Stay (Physician)
30% Coinsurance after deductible
Outpatient Procedure (Facility)
30% Coinsurance after deductible
Outpatient Procedure (Physician)
30% Coinsurance after deductible

Pregnancy

Delivery
30% Coinsurance after deductible
Well Baby Visits
0

Mental Health

Outpatient Services
$20 copay
Psychiatric Hospital Stay
30% Coinsurance after deductible

Diagnostics / Labs / Imaging

X-Rays
30% Coinsurance after deductible
CT Scans, Pet Scans and MRIs
30% Coinsurance after deductible
Lab Tests
30% Coinsurance after deductible

Free Preventative Care

If you use an in-network doctor, this plan will provide all preventative care services at no cost.

List of covered services

Out of Network

If you use out-of-network providers under this plan, you may have to pay more or even full price. Out of Network care doesn't count towards your deductible and maximum out-of-pocket.