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PacificSource Health Plans

Navigator Bronze HSA 7000

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $7,000
  • Family: $14,000
  • Per Person: $7,000
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $7,000
  • Family: $14,000
  • Per Person: $7,000

Office Visit

Primary Doctor
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Missed appointments and get acquainted visits. See policy for more information.
Specialist
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Missed appointments and get acquainted visits. See policy for more information.

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Benefit Explanation: Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $75 max out of pocket for 30 day supply prior to deductible. See policy for more information.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Benefit Explanation: Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $75 max out of pocket for 30 day supply prior to deductible. See policy for more information.
Generic Drugs
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Benefit Explanation: 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.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Charges for inpatient stays that began before you were covered by this plan.
  • Benefit Explanation: 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 Services
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Charges for inpatient stays that began before you were covered by this plan.
  • Benefit Explanation: 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.
Urgent Care Facility
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Benefit Period
  • Exclusions: Orthoptics, vision therapy, or other services to correct refractive error.
  • Benefit Explanation: Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Routine Dental Checkups for Adults
  • Covered: Not Covered
Basic Dental Care - Adult
  • Covered: Not Covered
Basic Dental Care - Child
  • Covered: Not Covered
Major Dental Care - Adult
  • Covered: Not Covered
Major Dental Care - Child
  • Covered: Not Covered
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