Navigator Silver 3500 (87) – PPO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	PPO
Deductible	$1,100 per person $1,100 per person
Out-of-pocket max	$1,800 per person $3,600 per family
Metal tier	Silver

Visit Copay

Primary care visit	20% coinsurance after deductible
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	20% coinsurance after deductible
Brand	20% coinsurance after deductible
Non-preferred Brand	20% coinsurance after deductible
Specialty	20% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://pacificsource.acquiadam.com/directdownload.php?ti=187514620&tok=06F5McwxvcdCmPqCWOsZ3gRR&token=$2y$10$bjdeLoVuUAU/.hrhSAe1zeQaEYgc/hGAn8NQPETOOvdvjCeo4QgQy&in=1&.pdf
Drug and medication plan formulary	https://pacificsource.com/ps_find_drug/pdf/MT/2024
Search doctor list	https://providerdirectory.pacificsource.com/