PacificSource Oregon Standard Silver Plan NAV (94) – PPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	PPO
Deductible	$150 per person $150 per person
Out-of-pocket max	$1,075 per person $2,150 per family
Metal tier	Silver

Visit Copay

Primary care visit	$10 copay
Specialist visit	$20 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$30 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	$10 copay

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$10 copay
Non-preferred Brand	25% coinsurance
Specialty	25% 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	$10 copay
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://pacificsource.acquiadam.com/directdownload.php?ti=188335055&tok=KxQN3IjIsWZayMojTgL4SgRR&token=$2y$10$DWr0lDYyY.4RsS.klUmw2OobzVV4bPXvGTex4XmmDfKoePqH/DNYK&in=1&.pdf
Drug and medication plan formulary	https://pacificsource.com/ps_find_drug/pdf/OR/2024
Search doctor list	https://providerdirectory.pacificsource.com/