Navigator Silver HSA 3500 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$3,500 per person $3,500 per person
Out-of-pocket max	$6,700 per person $13,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	25% coinsurance after deductible
Specialist visit	25% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	25% coinsurance after deductible
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	25% coinsurance after deductible
Psychiatric hospital stay	25% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://pacificsource.acquiadam.com/directdownload.php?ti=187514584&tok=XIXL3J4Ol2h0gDAyKK4psARR&token=$2y$10$2NXJ6FjtkJlybVyoJFMwJ.DQ87DnoImWDb9bWEJ3RwnWaMWCMlN4S&in=1&.pdf
Drug and medication plan formulary	https://pacificsource.com/ps_find_drug/pdf/MT/2024
Search doctor list	https://providerdirectory.pacificsource.com/