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Navigator Gold 500 Exchange

10091OR0760005
Gold
PPO

Navigator Gold 500 Exchange is a Gold PPO plan by PacificSource Health Plans.

IMPORTANT: You are viewing the 2024 version of Navigator Gold 500 Exchange 10091OR0760005. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Navigator Gold 500 Exchange is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Navigator Gold 500 Exchange 10091OR0760005.
Insurer: PacificSource Health Plans
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 10091OR0760005

Cost-Sharing Overview

Navigator Gold 500 Exchange offers the following cost-sharing.

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 Gold 500 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 Gold 500 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 Gold 500 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 Gold 500 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
$25.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible Missed appointments and get acquainted visits. See policy for more information.
Specialist Visit
Covered
$50.00 Not ApplicableNot 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
$25.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Hospice Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot 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)
Covered
No Charge Not ApplicableNo Charge Not Applicable
Urgent Care Centers or Facilities
Covered
$25.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Home Health Care Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Emergency Room Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 30.00% 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.
Emergency Transportation/Ambulance
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot 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 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Bariatric Surgery
Not Covered
Cosmetic Surgery
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible1.0 Procedure(s) per Episode
Skilled Nursing Facility
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible60.0 Days per Year Confinement for custodial care is not covered. See policy for more information.
Prenatal and Postnatal Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$25.00 Not ApplicableNot 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 30.00% Coinsurance after deductibleNot 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
$25.00 Not ApplicableNot 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 30.00% Coinsurance after deductibleNot 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
$25.00 Not ApplicableNot Applicable 90.00% Coinsurance after deductible
Preferred Brand Drugs
Covered
$50.00 Not ApplicableNot 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 30.00%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 30.00%Not Applicable 90.00% Coinsurance after deductible Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.
Outpatient Rehabilitation Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information.
Habilitation Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information.
Chiropractic Care
Covered
$25.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible20.0 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 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Hearing Aids
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Hearing assistance coverage complies with state and federal law.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 50.00% Coinsurance after deductible
Routine Foot Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Acupuncture
Covered
$25.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible12.0 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
Not Applicable No ChargeNot Applicable No Charge1.0 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
No Charge Not ApplicableNot Applicable No Charge1.0 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 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible30.0 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 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible30.0 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 ChargeNot Applicable 50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
Not Applicable 30.00% Coinsurance after deductibleNot 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
Not Applicable No ChargeNot Applicable No Charge
Transplant
Covered
Not Applicable No Charge after deductibleNot Applicable 50.00% Coinsurance after deductible
Accidental Dental
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Dialysis
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Allergy Testing
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Chemotherapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Radiation
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Diabetes Education
Covered
$25.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Prosthetic Devices
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Infusion Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
$25.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible5.0 Visit(s) per Lifetime
Reconstructive Surgery
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Gender Affirming Care
Covered
Not Applicable Not ApplicableNot Applicable Not Applicable Information about gender affirming care can be found in plan documents.
Telehealth – Primary Care Visit
Covered
$25.00 Not ApplicableNot 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
$50.00 Not ApplicableNot 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 Gold 500 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.

Additional Resources

Below are additional resources for Navigator Gold 500 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 Gold 500 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

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