Navigator Silver 4000 Exchange (87) – PPO
87% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $30 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $1,200 per person $1,200 per person |
| Out-of-pocket max | $2,000 per person $4,000 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=188335085&tok=dsgHnv1n9VcscRj0/QwzvgRR&token=$2y$10$QRxklvvdaEaZi5T99IIKX.vSATVb4CgePbtMUweHwoTlkG2Lwr8Ke&in=1&.pdf |
| Drug and medication plan formulary | https://pacificsource.com/ps_find_drug/pdf/OR/2024 |
| Search doctor list | https://providerdirectory.pacificsource.com/ |
