PacificSource Oregon Standard Silver Plan NAV (87) – PPO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	PPO
Deductible	$1,325 per person $1,325 per person
Out-of-pocket max	$3,150 per person $6,300 per family
Metal tier	Silver

Visit Copay

Primary care visit	$15 copay
Specialist visit	$30 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$40 copay
Emergency room	10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	$15 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	$25 copay
Non-preferred Brand	50% coinsurance
Specialty	50% coinsurance

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$15 copay
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://pacificsource.acquiadam.com/directdownload.php?ti=188335038&tok=UnwIMRm/jJcs6pq9Al4kOwRR&token=$2y$10$JAmFieUVEeFKYKll7IZE7exVJ8DEzqWSQWD8WL6NM73CxZ6NttJpW&in=1&.pdf
Drug and medication plan formulary	https://pacificsource.com/ps_find_drug/pdf/OR/2024
Search doctor list	https://providerdirectory.pacificsource.com/