Navigator Silver 5000 (94) – PPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	PPO
Deductible	$300 per person $300 per person
Out-of-pocket max	$675 per person $1,350 per family
Metal tier	Silver

Visit Copay

Primary care visit	$25 copay
Specialist visit	$50 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$25 copay
Emergency room	30% coinsurance 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
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	30% coinsurance after deductible
Brand	30% coinsurance after deductible
Non-preferred Brand	30% coinsurance after deductible
Specialty	30% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$25 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://pacificsource.acquiadam.com/directdownload.php?ti=187514622&tok=JT6fta22PQjZhDpAwzPoGARR&token=$2y$10$dE33tDUshRpawjxbITZi5.yWy7K10RruXBuO4AfcKdvBLlq2nad4.&in=1&.pdf
Drug and medication plan formulary	https://pacificsource.com/ps_find_drug/pdf/MT/2024
Search doctor list	https://providerdirectory.pacificsource.com/