Navigator Silver 4000 Exchange – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $30 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $4,000 per person $4,000 per person |
| Out-of-pocket max | $9,100 per person $18,200 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 | 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | 30% coinsurance after deductible |
| Brand | 30% coinsurance after deductible |
| Non-preferred Brand | 30% coinsurance after deductible |
| Specialty | 30% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | 30% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://pacificsource.acquiadam.com/directdownload.php?ti=188335088&tok=sRDN5ADT2EweJpCX1/fHPgRR&token=$2y$10$CTsL8eDmLeiXVHgD/TOO0.VkBVAhm3eh.fXkRhFZwMgq6jC1DLWd2&in=1&.pdf |
| Drug and medication plan formulary | https://pacificsource.com/ps_find_drug/pdf/OR/2024 |
| Search doctor list | https://providerdirectory.pacificsource.com/ |
