Navigator Standard Silver – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $5,900 per person $5,900 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | 40% coinsurance after deductible |
| Ambulance | 40% coinsurance after deductible |
| Hospital stay (facility) | 40% coinsurance after deductible |
| Hospital stay (physician) | 40% coinsurance after deductible |
| Outpatient procedure (facility) | 40% coinsurance after deductible |
| Outpatient procedure (physician) | 40% coinsurance after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $40 copay |
| Non-preferred Brand | $80 copay after deductible |
| Specialty | $350 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://pacificsource.acquiadam.com/directdownload.php?ti=187514626&tok=CQb77dvMf839YZRLk7DmoARR&token=$2y$10$z3tLM7aZVHKZsVvh6FNtIutoqxdo3xKMCpMeQYKa.c9hAh831MhXi&in=1&.pdf |
| Drug and medication plan formulary | https://pacificsource.com/ps_find_drug/pdf/MT/2024 |
| Search doctor list | https://providerdirectory.pacificsource.com/ |
