PacificSource Cascade Silver – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: first 2 visit(s) $1 then $30 copay
Specialist visit: $65 copay
Urgent care visit: $65 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $2,500 per person $2,500 per person |
| Out-of-pocket max | $9,200 per person $18,400 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | first 2 visit(s) $1 then $30 copay |
| Specialist visit | $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $65 copay |
| Emergency room | $800 copay after deductible |
| Ambulance | $375 copay |
| Hospital stay (facility) | first 5 day(s) $800 per day then $0 copay after deductible |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $600 copay after deductible |
| Outpatient procedure (physician) | $200 copay after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $800 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 per script copay |
| Brand | $75 per script copay |
| Non-preferred Brand | $250 per script after deductible copay |
| Specialty | $250 per script after deductible copay |
Lab Tests and Diagnostic Procedures
| X-rays | $65 per procedure copay |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | $40 per procedure copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 2 visit(s) $1 then $30 copay |
| Psychiatric hospital stay | first 5 day(s) $800 per day then $0 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/v2hNSuoQ177GWkZjBxTRjMU9.pdf |
| Drug and medication plan formulary | https://pacificsource.com/find-a-drug |
