Navigator Gold 1500 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$7,000 per person $14,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	10% coinsurance after deductible
Specialist visit	10% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	10% coinsurance after deductible
Emergency room	10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	$50 copay
Non-preferred Brand	$75 copay
Specialty	$250 copay

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	10% coinsurance after deductible
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://pacificsource.acquiadam.com/directdownload.php?ti=187514636&tok=5zNCanykQAxBkH4PAzXESgRR&token=$2y$10$WXpDDliSpm1eUjrxW/TlEudYpOhfjrFr17JOBEFtKBpXc.S0GH.F2&in=1&.pdf
Drug and medication plan formulary	https://pacificsource.com/ps_find_drug/pdf/MT/2024
Search doctor list	https://providerdirectory.pacificsource.com/