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/ |