Navigator Silver 4000 Exchange (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	$600 per person $1,200 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay
Specialist visit	$60 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$30 copay
Emergency room	25% coinsurance after deductible
Ambulance	25% coinsurance after deductible
Hospital stay (facility)	25% coinsurance after deductible
Hospital stay (physician)	25% coinsurance after deductible
Outpatient procedure (facility)	25% coinsurance after deductible
Outpatient procedure (physician)	25% coinsurance after deductible
Physical rehabilitation	25% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	25% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	25% coinsurance after deductible
Brand	25% coinsurance after deductible
Non-preferred Brand	25% coinsurance after deductible
Specialty	25% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	25% coinsurance after deductible
Imaging (CT/PET/MRI)	25% coinsurance after deductible
Blood work	25% coinsurance after deductible

Mental and Psychiatric Health Care

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

Health Plan Provider Information

Health Plan Benefits	https://pacificsource.acquiadam.com/directdownload.php?ti=188335087&tok=qYJLhiqJNo79TqseTf4FYgRR&token=$2y$10$gdb4rPVrZYZsPR/uVnplzeWTd7mEohkLb78aBojHqzRYA9Tuz/.W.&in=1&.pdf
Drug and medication plan formulary	https://pacificsource.com/ps_find_drug/pdf/OR/2024
Search doctor list	https://providerdirectory.pacificsource.com/