Voyager Silver 3600 – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $70 copay after deductible
Urgent care visit: $35 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $3,600 per person $3,600 per person |
| Out-of-pocket max | $9,400 per person $18,800 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $70 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $35 copay |
| Emergency room | 40% after deductible |
| Ambulance | 40% after deductible |
| Hospital stay (facility) | 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | 40% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 per script copay |
| Brand | $60 per script copay |
| Non-preferred Brand | 40% coinsurance |
| Specialty | 40% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 40% after deductible |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | 40% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/qxw6Azbi7LWCSXJcLm8P624j.pdf |
| Drug and medication plan formulary | https://pacificsource.com/find-a-drug |
