Navigator Standard Silver

23603MT0290017
Silver
PPO

Navigator Standard Silver is a Silver PPO plan by PacificSource Health Plans.

IMPORTANT: You are viewing the 2023 version of Navigator Standard Silver 23603MT0290017. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

Navigator Standard Silver is offered in the following counties.

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Plan Overview

This is a plan overview for 2023 version of Navigator Standard Silver 23603MT0290017.
Insurer: PacificSource Health Plans
Network Type: PPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 23603MT0290017

Cost-Sharing Overview

Navigator Standard Silver 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 Standard Silver?

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 Standard Silver 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 Standard Silver 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: Non-Participating Providers
National Network: Yes

Additional Benefits and Cost-Sharing

Navigator Standard Silver 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
$40.00 50.00% Coinsurance after deductible Missed appointments and get acquainted visits. See policy for more information.
Specialist Visit
Covered
$80.00 50.00% Coinsurance after deductible Missed appointments and get acquainted visits. See policy for more information.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hospice Services
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
No Charge after deductible 100.00% Services and supplies for in vitro fertilization, erectile dysfunction, sexual dysfunction, or surgery to reverse voluntary sterilization. Services provided by out-of-network providers are not covered. Treatment includes services to diagnose infertility, services related to artificial insemination.
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Not Covered
Private duty nurse not covered.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 50.00% Coinsurance after deductible
Home Health Care Services
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible The benefit does not cover further treatment provided on referral from the emergency room. For emergency medical conditions, out-of-network providers are paid at the in-network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Bariatric Surgery
Not Covered
Cosmetic Surgery
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible60 Days per Benefit Period Confinement or custodial care is not covered. See policy for more information.
Prenatal and Postnatal Care
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$40.00 50.00% Coinsurance after deductible This health plan complies with all federal laws an regulations related to the Mental Health Parity and Addiction Equity Act of 2008.
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible This health plan complies with all federal laws an regulations related to the Mental Health Parity and Addiction Equity Act of 2008.
Substance Abuse Disorder Outpatient Services
Covered
$40.00 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Generic Drugs
Covered
$20.00 50.00% Coinsurance after deductible Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.
Preferred Brand Drugs
Covered
$40.00 50.00% Coinsurance after deductible Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 50.00% Coinsurance after deductible Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.
Specialty Drugs
Covered
$350.00 Copay after deductible 50.00% 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
$40.00 50.00% Coinsurance after deductible See policy for more information.
Habilitation Services
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible See policy for more information.
Chiropractic Care
Covered
$40.00 50.00% Coinsurance after deductible10 Visit(s) per Benefit Period Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies.
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hearing Aids
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible The diagnosis and treatment of hearing loss and one amplification device for each ear every three years as required be an audiologist for members age 18 and younger.
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
0.00% 25.00% Coinsurance after deductible
Routine Foot Care
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Acupuncture
Covered
$40.00 50.00% Coinsurance after deductible12 Visit(s) per Year Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies.
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge 1 Visit(s) per Benefit Period Orthoptics, vision therapy, or other services to correct refractive error. When using an in-network provider eye exams are covered in full. When using an out-of-network provider the first $40 is covered and the remaining cost is member responsibility.
Eye Glasses for Children
Covered
No Charge 40.00% Coinsurance after deductibleNo Charge 40.00% Coinsurance after deductible1 Item(s) per Benefit Period Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 50.00% Coinsurance after deductible
Well Baby Visits and Care
Covered
0.00% 25.00%
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 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
Not Covered
Transplant
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Accidental Dental
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Dialysis
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Allergy Testing
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Chemotherapy
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Radiation
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Education
Covered
$40.00 50.00% Coinsurance after deductible
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Infusion Therapy
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
$40.00 50.00% Coinsurance after deductible
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Gender Affirming Care
Not Covered
Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.

Free Preventive Services

There is no copayment or coinsurance for any of the following Navigator Standard Silver 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 Standard Silver 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 Standard Silver?

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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