Navigator PPO Plans offer a three-tier benefit structure that gives employees the flexibility to choose care that best fits their health and financial needs.
All PPO Plans include access to Care Advocates who can negotiate lower costs for certain care at hospitals and facilities, often with a $0 copay, when you contact a Care Advocate prior to receiving hospital and facility care. Coverage and costs vary by plan.
Tier 1Care Advocate | 4000 Plan | 4500 Plan | 6000 Plan | 6500 Plan |
---|---|---|---|---|
Deductible (Single / Family) | None | None | None | None |
Out-of-Pocket Limit (Single / Family) | None | None | None | None |
Tier 2In-Network | 4000 Plan | 4500 Plan | 6000 Plan | 6500 Plan |
Deductible (Single / Family) | $4,000 / $8,000 | $4,500 / $9,000 | $6,000 / $12,000 | $6,500 / $13,000 |
Out-of-Pocket Limit (Single / Family) | $7,050 / $14,100 | $7,050 / $14,100 | $7,050 / $14,100 | $7,050 / $14,100 |
Tier 3Out-of-Network | 4000 Plan | 4500 Plan | 6000 Plan | 6500 Plan |
Deductible (Single / Family) | $8,000 / $16,000 | $9,000 / $18,000 | $12,000 / $24,000 | $13,000 / $26,000 |
Out-of-Pocket Limit (Single / Family) | Unlimited | Unlimited | Unlimited | Unlimited |
Schedule of Benefits | Schedule of Benefits | Schedule of Benefits | Schedule of Benefits |
Care Advocates
The cost of care at hospitals and facilities can be expensive for both members and employers. Care Advocates can negotiate lower costs on your behalf, often with a $0 copay.
The benefit coinsurances and copayments listed here are for Navigator PPO Advantage HDHP 4000. Please see the full Plan Summaries for Navigator PPO Advantage HDHP 4500, 6000, and 6500.
Physician & Ancillary Services | Care Advocate | In-Network | Out-of-Network |
---|---|---|---|
Primary Care Office Visit | Not Applicable | 20% Coinsurance ** | 50% Coinsurance *** |
Specialist Office Visit | Not Applicable | 20% Coinsurance ** | 50% Coinsurance *** |
Other Services (Performed in Office) | Not Applicable | 20% Coinsurance ** | 50% Coinsurance *** |
Physician Services (Performed in a Facility) | Not Applicable | 20% Coinsurance ** § | 50% Coinsurance *** § |
Urgent Care Visit | Not Applicable | 20% Coinsurance ** | 50% Coinsurance *** |
Maternity Physician Services | Not Applicable | 20% Coinsurance ** §§ | 50% Coinsurance *** §§ |
Lab Services (Non-Hospital) | Not Applicable | 20% Coinsurance ** | 50% Coinsurance *** |
Rehab & Therapy (Non-Hospital) | Not Applicable | 20% Coinsurance ** § | 50% Coinsurance *** § |
Alternative Care (Chiropractic, Acupuncture, Massage Therapy) | Not Applicable | 20% Coinsurance ** | 50% Coinsurance *** |
Facility-Based Services | Care Advocate | In-Network | Out-of-Network |
Emergency Services Hospital ER (Facility Charge Only) | Not Applicable | 20% Coinsurance ** | 50% Coinsurance *** |
Ambulance – Emergent (Ground Only) | Not Applicable | 20% Coinsurance ** | 50% Coinsurance *** |
Radiology (Hospital Outpatient) | Not Applicable | 20% Coinsurance ** § | 50% Coinsurance *** § |
Dialysis & Supplies | Not Applicable | $3,050 Copayment ** § | 50% Coinsurance *** § |
Outpatient Services (Cardiac, Pulmonary, PT, OT, ST) | 0% Copay / 0% Coinsurance * | 20% Coinsurance ** § | 50% Coinsurance *** § |
Outpatient Surgeries | 0% Copay / 0% Coinsurance * | 20% Coinsurance ** § | 50% Coinsurance *** § |
Inpatient Hospitalizations | 0% Copay / 0% Coinsurance * | 20% Coinsurance ** § | 50% Coinsurance *** § |
Transplant Procedures | 0% Copay / 0% Coinsurance * | $3,050 Copayment ** § | 50% Coinsurance *** § |
Prescription Drug Benefits | Care Advocate | In-Network | Out-of-Network |
Preventive Prescription Services (Prescription Drugs, Pharmacy Retail – up to a 30-Day Supply) | Not Applicable | Generic - $0 Copayment | Not Covered |
Non-Preventive Prescription Services (Prescription Drugs, Pharmacy Retail – up to a 30-Day Supply) | Not Applicable | Generic / Preferred Brand - 20% Coinsurance ** | Not Covered |
Specialty Drugs | Not Applicable | 20% Coinsurance ** | Not Covered |