PPO Prime

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	3500 Plan	4000 Plan	4500 Plan	6000 Plan
Deductible (Single / Family)	None	None	None	None
Out-of-Pocket Limit (Single / Family)	None	None	None	None
Tier 2In-Network	3500 Plan	4000 Plan	4500 Plan	6000 Plan
Deductible (Single / Family)	$3,500 / $7,000	$4,000 / $8,000	$4,500 / $9,000	$6,000 / $12,000
Out-of-Pocket Limit (Single / Family)	$8,700 / $17,400	$8,700 / $17,400	$8,700 / $17,400	$8,700 / $17,400
Tier 3Out-of-Network	3500 Plan	4000 Plan	4500 Plan	6000 Plan
Deductible (Single / Family)	$7,000 / $14,000	$8,000 / $16,000	$9,000 / $18,000	$12,000 / $24,000
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 Prime 3500. Please see the full Plan Summaries for Navigator PPO Prime 4000, 4500, and 6000.

Physician & Ancillary Services	Care Advocate	In-Network	Out-of-Network
Primary Care Office Visit	Not Applicable	$5 Copay (Per Visit)	50% Coinsurance ^***
Specialist Office Visit	Not Applicable	$50 Copay (Per Visit)	50% Coinsurance ^***
Other Services (Performed in Office)	Not Applicable	0% Coinsurance ^**	50% Coinsurance ^***
Physician Services (Performed in a Facility)	Not Applicable	0% Coinsurance ^{** §}	50% Coinsurance ^{*** §}
Urgent Care Visit	Not Applicable	$50 Copay (Per Visit)	50% Coinsurance ^***
Maternity Physician Services	Not Applicable	0% Coinsurance ^{** §§}	50% Coinsurance ^{*** §§}
Lab Services (Non-Hospital)	Not Applicable	0% Coinsurance ^**	50% Coinsurance ^***
Rehab & Therapy (Non-Hospital)	Not Applicable	0% Coinsurance ^{** §}	50% Coinsurance ^{*** §}
Alternative Care (Chiropractic, Acupuncture, Massage Therapy)	Not Applicable	$50 Copay (Per Visit)	50% Coinsurance ^***
Facility-Based Services	Care Advocate	In-Network	Out-of-Network
Emergency Services Hospital ER (Facility Charge Only)	Not Applicable	$1,000 Copayment ^†	$1,000 Copayment ^†††
Ambulance – Emergent (Ground Only)	Not Applicable	$500 Copayment ^**	$500 Copayment ^††
Radiology (Hospital Outpatient)	Not Applicable	0% Coinsurance ^{** §}	50% Coinsurance ^{*** §}
Dialysis & Supplies	Not Applicable	$5,200 Copayment ^{** §}	50% Coinsurance ^{*** §}
Outpatient Services (Cardiac, Pulmonary, PT, OT, ST)	0% Copay / 0% Coinsurance ^*	$50 Copayment ^{** §}	$50 Copayment ^{†† §}
Outpatient Surgeries	0% Copay / 0% Coinsurance ^*	$1,000 Copayment ^{** §}	$1,000 Copayment ^{†† §}
Inpatient Hospitalizations	0% Copay / 0% Coinsurance ^*	$1,500 Copayment ^{** §}	$1,500 Copayment ^{†† §}
Transplant Procedures	0% Copay / 0% Coinsurance ^*	$5,200 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 - $10 Copay Preferred Brand - $20 Copay	Not Covered
Specialty Drugs	Not Applicable	50% Coinsurance	Not Covered

^* Cannot guarantee a “Care Advocate” option will be available in your area for every medical service or procedure in this category. Some travel may be necessary to receive
$0 Copay for larger-cost, non-emergency procedures.
^** After Annual Deductible.
^*** After Annual Deductible plus amounts that exceed the Maximum Allowed Charge.
^† After Annual Deductible (Copay waived if admitted).
^†† After Annual Deductible then 50% Coinsurance plus amounts that exceed the Maximum Allowed Charge.
^††† After Annual Deductible (Copay waived if admitted) plus amounts that exceed the Maximum Allowable Charge.
^§ Prior authorization required. If prior authorization is not obtained, there are no benefits.
^§§ No prior authorization required unless stay exceeds 48 hours or 96 hours for caesarian section.