PacificSource Oregon Standard Bronze Plan NAV – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay
Specialist visit: $150 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $9,450 per person $9,450 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $150 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay |
| Emergency room | No charge after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | No charge after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | No charge after deductible |
| Non-preferred Brand | No charge after deductible |
| Specialty | No charge after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | No charge after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://pacificsource.acquiadam.com/directdownload.php?ti=188335041&tok=tctGwaRTG15B2Vhcgg/CkwRR&token=$2y$10$zvtV7AmIqVpYvIUmnwkcruB3SR94Y46oVTdDLatfW2gqN3AE0SmaK&in=1&.pdf |
| Drug and medication plan formulary | https://pacificsource.com/ps_find_drug/pdf/OR/2024 |
| Search doctor list | https://providerdirectory.pacificsource.com/ |
