Navigator Gold 1500 Exchange – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $25 copay
Specialist visit: $50 copay
Urgent care visit: $25 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $1,500 per person $1,500 per person |
| Out-of-pocket max | $7,500 per person $15,000 per family |
| Metal tier | Gold |
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 | 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 | $25 copay |
| Brand | $50 copay |
| Non-preferred Brand | 20% coinsurance |
| Specialty | 20% coinsurance |
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 | $25 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://pacificsource.acquiadam.com/directdownload.php?ti=188335076&tok=nI3uybkukcH89V0e1m6GrQRR&token=$2y$10$8rOkp4/0KnAtFcY6iGE2IuUMNK/lvb.fO/El94Gqrz2USlu229/pG&in=1&.pdf |
| Drug and medication plan formulary | https://pacificsource.com/ps_find_drug/pdf/OR/2024 |
| Search doctor list | https://providerdirectory.pacificsource.com/ |
