Navigator Silver 5000 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$5,000 per person $5,000 per person
Out-of-pocket max	$7,600 per person $15,200 per family
Metal tier	Silver

Visit Copay

Primary care visit	$35 copay
Specialist visit	$70 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$35 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	$35 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://pacificsource.acquiadam.com/directdownload.php?ti=187514619&tok=AgyeK1nW3pBbNxx3E2wVVARR&token=$2y$10$WAM50eLrJzsXZCIdyt1m3OYPg21y1ujOQIb9TJXVG6nnx2.W3l9gK&in=1&.pdf
Drug and medication plan formulary	https://pacificsource.com/ps_find_drug/pdf/MT/2024
Search doctor list	https://providerdirectory.pacificsource.com/