PacificSource Cascade Silver – PPO
87% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: first 2 visit(s) $1 then $10 copay
Specialist visit: $30 copay
Urgent care visit: $30 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $750 per person $750 per person |
| Out-of-pocket max | $2,500 per person $5,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | first 2 visit(s) $1 then $10 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $30 copay |
| Emergency room | $425 copay after deductible |
| Ambulance | $175 copay |
| Hospital stay (facility) | first 5 day(s) $425 per day then $0 copay after deductible |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $325 copay after deductible |
| Outpatient procedure (physician) | $120 copay after deductible |
| Physical rehabilitation | $20 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $425 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $12 per script copay |
| Brand | $35 per script copay |
| Non-preferred Brand | $160 per script copay |
| Specialty | $160 per script copay |
Lab Tests and Diagnostic Procedures
| X-rays | $40 per procedure copay |
| Imaging (CT/PET/MRI) | 20% after deductible |
| Blood work | $20 per procedure copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 2 visit(s) $1 then $10 copay |
| Psychiatric hospital stay | first 5 day(s) $425 per day then $0 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/Lp6rf8wJH59mPJ9UyVtvzxMF.pdf |
| Drug and medication plan formulary | https://pacificsource.com/find-a-drug |
