Navigator Bronze 9400 Exchange
10091OR0750018
Expanded Bronze
PPO
Navigator Bronze 9400 Exchange is an Expanded Bronze PPO plan by PacificSource Health Plans.
IMPORTANT: You are viewing the 2024 version of Navigator Bronze 9400 Exchange 10091OR0750018. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
Navigator Bronze 9400 Exchange is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of Navigator Bronze 9400 Exchange 10091OR0750018.
| Insurer: | PacificSource Health Plans |
| Network Type: | PPO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | No |
| Plan ID: | 10091OR0750018 |
Cost-Sharing Overview
Navigator Bronze 9400 Exchange offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Navigator Bronze 9400 Exchange includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9400 per person | $18800 per group |
| Deductible: | $9400 per person | $18800 per group |
| Coinsurance: | 0.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Navigator Bronze 9400 Exchange will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | $25000 per person | $50000 per group |
| Out-of-Network Deductible: | $10000 per person | $20000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $9,400.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $60.00 |
| Deductible: | $5,400.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,800.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Navigator Bronze 9400 Exchange?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Navigator Bronze 9400 Exchange offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | Asthma, Heart Disease, Diabetes, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Navigator Bronze 9400 Exchange covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | Emergency Care Only |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | In and out-of-network providers |
| National Network: | Yes |
Additional Benefits and Cost-Sharing
Navigator Bronze 9400 Exchange includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | Missed appointments and get acquainted visits. See policy for more information. |
| Specialist Visit Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | Missed appointments and get acquainted visits. See policy for more information. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | Missed appointments and get acquainted visits. See policy for more information. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Hospice Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Not Covered | |||
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Home Health Care Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Emergency Room Services Covered | Not Applicable No Charge after deductible | Not Applicable No Charge after deductible | Charges for inpatient stays that began before you were covered by this plan. Charges for a hospital room are covered up to the hospital’s semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation. |
| Emergency Transportation/Ambulance Covered | Not Applicable No Charge after deductible | Not Applicable No Charge after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | Charges for inpatient stays that began before you were covered by this plan. Charges for a hospital room are covered up to the hospital?s semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation. |
| Inpatient Physician and Surgical Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | 1.0 Procedure(s) per Episode |
| Skilled Nursing Facility Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | 60.0 Days per Year Confinement for custodial care is not covered. See policy for more information. |
| Prenatal and Postnatal Care Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Mental/Behavioral Health Outpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
| Substance Abuse Disorder Outpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
| Generic Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 90.00% Coinsurance after deductible | |
| Preferred Brand Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 90.00% Coinsurance after deductible | Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $85 max out of pocket for 30 day supply prior to deductible. See policy for more information. |
| Non-Preferred Brand Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 90.00% Coinsurance after deductible | Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $85 max out of pocket for 30 day supply prior to deductible. See policy for more information. |
| Specialty Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 90.00% Coinsurance after deductible | Certain drugs may fall under a higher or lower cost sharing amount than is listed here. $500 cap per script for Standard Gold Plans. See policy for more information. |
| Outpatient Rehabilitation Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
| Habilitation Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
| Chiropractic Care Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | 20.0 Visit(s) per Year Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. |
| Durable Medical Equipment Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Hearing Aids Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | Hearing assistance coverage complies with state and federal law. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Preventive Care/Screening/Immunization Covered | Not Applicable No Charge | Not Applicable 50.00% Coinsurance after deductible | |
| Routine Foot Care Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Acupuncture Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | 12.0 Visit(s) per Year Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. |
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | No Charge Not Applicable | Not Applicable No Charge | 1.0 Visit(s) per Benefit Period Orthoptics, vision therapy, or other services to correct refractive error. Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. In network: Covered in Full. Out of network: No charge up to $40 maximum, and the remaining cost is member responsibility. |
| Eye Glasses for Children Covered | Not Applicable No Charge | Not Applicable No Charge | 1.0 Item(s) per Benefit Period No charge up to $150 maximum then subject to medical deductible and coinsurance. See policy for more information. |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
| Well Baby Visits and Care Covered | Not Applicable No Charge | Not Applicable 50.00% Coinsurance after deductible | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | |||
| Abortion for Which Public Funding is Prohibited Covered | No Charge Not Applicable | Not Applicable No Charge | |
| Transplant Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Accidental Dental Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Dialysis Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Allergy Testing Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Chemotherapy Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Radiation Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Diabetes Education Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Prosthetic Devices Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Infusion Therapy Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Treatment for Temporomandibular Joint Disorders Not Covered | |||
| Nutritional Counseling Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Reconstructive Surgery Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Gender Affirming Care Covered | Not Applicable Not Applicable | Not Applicable Not Applicable | Information about gender affirming care can be found in plan documents. |
| Telehealth – Primary Care Visit Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | For services that are performed and billed as a true telemedicine visits, copays will be waived. HSA qualified plans will still be subject to the deductible and coinsurance. |
| Telehealth – Specialist Visit Covered | Not Applicable No Charge after deductible | Not Applicable 50.00% Coinsurance after deductible | For services that are performed and billed as a true telemedicine visits, copays will be waived. HSA qualified plans will still be subject to the deductible and coinsurance. |
Free Preventive Services
There is no copayment or coinsurance for any of the following Navigator Bronze 9400 Exchange preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Navigator Bronze 9400 Exchange including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Navigator Bronze 9400 Exchange?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904