Montana health plan · 2025

Dental Choice Core · 23603MT0330001

PacificSource Health Plans offers this marketplace plan (Plan ID 23603MT0330001). Use the modules below to compare premiums, coverage structure, provider access, and formulary context against alternative options in the same market.

Metal level: High Plan type: Indemnity CSR: Standard High Off Exchange Plan Issuer: PacificSource Health Plans
Telehealth Data pending HSA eligible Check with issuer Dental Adult/Child Vision Not listed
View issuer site

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 10 Mar 2026 06:40 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$27 – $51

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

N/A

N/A

Review MOOP rules

Office visits

Primary care See benefits
Specialist See benefits

Drug tiers

Generic See drug coverage
Preferred brand See drug coverage

View formulary tiers

$29 / mo before subsidies

≈ $353 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$124 / mo before subsidies

≈ $1488 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$166 / mo before subsidies

≈ $1995 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$75 / mo before subsidies

≈ $901 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits
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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Montana). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard High Off Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 23603MT0330001
Coverage year 2025
State Montana
Issuer PacificSource Health Plans
Marketing materials View marketing kit
Variant ID 23603MT0330001-00
Available variants

Standard Off Exchange Plan · 23603MT0330001-00
Last plan update Fri, 13 Sep 2024 00:00 GMT
Last HealthPorta import Tue, 10 Mar 2026 06:40 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 10 Mar 2026 06:40 GMT).

All providers in Montana N/A
PCPs in Montana N/A
Telehealth support Data pending
Nationwide providers N/A
N/A doctors statewide N/A PCPs N/A OB/GYN

Provider network(s)

['MTN002']

Providers Montana All US states
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A

Drug coverage overview

0 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Prior authorization Drugs
Required 0
Not Required 0
Step therapy Drugs
Required 0
Not Required 0
Quantity limits Drugs
Has Limit 0
No Limit 0

Customer highlights

What stands out for members

  • Issuer: PacificSource Health Plans · Plan ID 23603MT0330001 · 2025 filing.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 23603MT0330001-00 (Standard Off Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.

Exclusions: nan

Major Dental Care - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Surgical placement and removal of implants 1 per tooth space per 60 months.

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Basic Dental Care - Adult

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.

Exclusions: nan

Dental Check-Up for Children

No Charge
Tier 1 in-network No Charge
Out-of-network No Charge

Limit: 2.0 Visit(s) per Year

Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Medically necessary orthodontia requires a predetermination and a treatment plan.

Exclusions: Coverage for orthodontia services are excluded unless medically necessary.

Routine Dental Services (Adult)

No Charge
Tier 1 in-network No Charge
Out-of-network No Charge

Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.

Exclusions: Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.

Variant attributes

Dental Choice Core · Variant 23603MT0330001-00

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Standard High Off Exchange Plan

HIOS Product ID

23603MT033

Metal Level

High

Plan ID (Standard Component ID with Variant)

23603MT0330001-00

Plan Marketing Name

Dental Choice Core

Plan Variant Marketing Name

Dental Choice Core

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

23603

Issuer Marketplace Marketing Name

PacificSource Health Plans

Market Coverage

SHOP (Small Group)

Multiple In Network Tiers

No

National Network

Yes

Network ID

MTN002

Out of Country Coverage

Yes

Out of Country Coverage Description

Emergency care only

Out of Service Area Coverage

Yes

Out of Service Area Coverage Description

This plan covers eligible services when performed by an eligible provider.

Service Area ID

MTS004

State Code

MT

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group

$850 per group

Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person

$425 per person

Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out

$425

Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group

per group not applicable

Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person

per person not applicable

Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual

Not Applicable

Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual

Not Applicable

Enrollment & documents

Issuer-provided metadata for this variant.

Plan Brochure

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

Yes

Dental Only Plan

Yes

First Tier Utilization

100%

Import Date

2024-09-13 20:01:37

Guaranteed Rate

Guaranteed Rate

New/Existing Plan

Existing

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

$150 per group

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

$50 per person

Medical EHB Deductible, Combined In/Out of Network, Individual

$50

Medical EHB Deductible, In Network (Tier 1), Family Per Group

per group not applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Person

per person not applicable

Medical EHB Deductible, In Network (Tier 1), Individual

Not Applicable

Medical EHB Deductible, Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Out of Network, Individual

Not Applicable

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

Indemnity

QHP/Non QHP

Off the Exchange

Source Name

SERFF

Plan ID

23603MT0330001

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Montana?

Dental Choice Core (23603MT0330001) is a High Indemnity from PacificSource Health Plans in Montana for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Dental Choice Core support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Dental Choice Core HSA-eligible and does it include dental or vision coverage?

HSA eligibility is not published; check the Summary of Benefits or ask the issuer.

Dental add-ons: Adult, Child.

Vision coverage is not listed for this plan.

Does Dental Choice Core support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Is there out-of-country coverage for Dental Choice Core?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Emergency care only

Does Dental Choice Core cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: This plan covers eligible services when performed by an eligible provider.

Disclaimer: Based on the Tue, 10 Mar 2026 06:40 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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