PacificSource Cascade Gold – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $40 copay
Urgent care visit: $35 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $600 per person $600 per person |
| Out-of-pocket max | $6,100 per person $12,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $35 copay |
| Emergency room | $450 copay after deductible |
| Ambulance | $375 copay |
| Hospital stay (facility) | first 5 day(s) $525 per day then $0 copay |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $350 copay after deductible |
| Outpatient procedure (physician) | $75 copay after deductible |
| Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $525 per day then $0 copay |
Pharmacy, Drugs, and Medication
| Generic | $10 per script copay |
| Brand | $60 per script copay |
| Non-preferred Brand | $100 per script copay |
| Specialty | $100 per script copay |
Lab Tests and Diagnostic Procedures
| X-rays | $30 per procedure copay |
| Imaging (CT/PET/MRI) | $300 per procedure after deductible copay |
| Blood work | $20 per procedure copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | first 5 day(s) $525 per day then $0 copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/d61V8o3sXbSi5VUGsem3dj7T.pdf |
| Drug and medication plan formulary | https://pacificsource.com/find-a-drug |
