Oregon health plan · 2025

Dental PPO 0-20-50 1000 · 10091OR0720001

PacificSource Health Plans offers this marketplace plan (Plan ID 10091OR0720001). Use the modules below to compare premiums, coverage structure, provider access, and formulary context against alternative options in the same market.

Metal level: High Plan type: PPO CSR: Standard High Off Exchange Plan Issuer: PacificSource Health Plans
Telehealth Data pending HSA eligible Check with issuer Dental Adult/Child Vision Not listed
Pay / Manage Plan View issuer site

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 10 Mar 2026 06:40 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$40 – $69

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

N/A

N/A

Review MOOP rules

Office visits

Primary care See benefits
Specialist See benefits

Drug tiers

Generic See drug coverage
Preferred brand See drug coverage

View formulary tiers

$44 / mo before subsidies

≈ $528 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$154 / mo before subsidies

≈ $1848 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$184 / mo before subsidies

≈ $2208 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$114 / mo before subsidies

≈ $1368 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits
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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Oregon). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard High Off Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 10091OR0720001
Coverage year 2025
State Oregon
Issuer PacificSource Health Plans
Marketing materials View marketing kit
Variant ID 10091OR0720001-00
Available variants

Standard Off Exchange Plan · 10091OR0720001-00

Standard On Exchange Plan · 10091OR0720001-01
Last plan update Thu, 01 Aug 2024 00:00 GMT
Last HealthPorta import Tue, 10 Mar 2026 06:40 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 10 Mar 2026 06:40 GMT).

All providers in Oregon N/A
PCPs in Oregon N/A
Telehealth support Data pending
Nationwide providers N/A
N/A doctors statewide N/A PCPs N/A OB/GYN

Provider network(s)

['ORN006']

Providers Oregon All US states
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A

Drug coverage overview

8,259 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
NON-PREFERRED-BRAND 4,713
GENERIC 3,220
SPECIALTY 326
Prior authorization Drugs
Required 2,727
Not Required 5,532
Step therapy Drugs
Required 178
Not Required 8,081
Quantity limits Drugs
Has Limit 2,422
No Limit 5,837

Customer highlights

What stands out for members

  • Issuer: PacificSource Health Plans · Plan ID 10091OR0720001 · 2025 filing.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 10091OR0720001-00 (Standard Off Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

20.00%
Tier 1 in-network 20.00%
Out-of-network 20.00% Coinsurance after deductible

Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction.

Exclusions: nan

Major Dental Care - Child

50.00%
Tier 1 in-network 50.00%
Out-of-network 50.00% Coinsurance after deductible

Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Surgical placement and removal of implants 1 per tooth space per lifetime.

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

50.00%
Tier 1 in-network 50.00%
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Basic Dental Care - Adult

20.00%
Tier 1 in-network 20.00%
Out-of-network 20.00% Coinsurance after deductible

Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 36 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.

Exclusions: nan

Dental Check-Up for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 20.00%

Limit: 2.0 Visit(s) per Year

Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 60 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.

Exclusions: nan

Major Dental Care - Adult

50.00%
Tier 1 in-network 50.00%
Out-of-network 50.00% Coinsurance after deductible

Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Crowns and other restorations 1 per tooth per 10 years. Replacement of existing prosthetic only when unserviceable and in place at least 10 years. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.

Exclusions: Separate charges for denture adjustments and relines performed within 6 months of initial placement.

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

50.00%
Tier 1 in-network 50.00%
Out-of-network 50.00% Coinsurance after deductible

Limited to members with diagnosis of cleft palate and or cleft lip when services are medically necessary.

Exclusions: Coverage for orthodontia services are excluded unless medically necessary.

Routine Dental Services (Adult)

No Charge
Tier 1 in-network No Charge
Out-of-network 20.00%

Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 60 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.

Exclusions: Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.

Variant attributes

Dental PPO 0-20-50 1000 · Variant 10091OR0720001-00

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Standard High Off Exchange Plan

HIOS Product ID

10091OR072

Metal Level

High

Plan ID (Standard Component ID with Variant)

10091OR0720001-00

Plan Marketing Name

Dental PPO 0-20-50 1000

Plan Variant Marketing Name

Dental PPO 0-20-50 1000

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

10091

Issuer Marketplace Marketing Name

PacificSource Health Plans

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

Yes

Network ID

ORN006

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

Service Area ID

ORS004

State Code

OR

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out

Not Applicable

Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group

$850 per group

Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person

$425 per person

Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual

$425

Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual

Not Applicable

Enrollment & documents

Issuer-provided metadata for this variant.

Plan Brochure

Open link

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Dental Only Plan

Yes

EHB Apportionment for Pediatric Dental

1.0

First Tier Utilization

100%

Import Date

2024-08-01 20:01:31

Guaranteed Rate

Guaranteed Rate

New/Existing Plan

Existing

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Group

per group not applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Person

per person not applicable

Medical EHB Deductible, In Network (Tier 1), Individual

Not Applicable

Medical EHB Deductible, Out of Network, Family Per Group

$150 per group

Medical EHB Deductible, Out of Network, Family Per Person

$50 per person

Medical EHB Deductible, Out of Network, Individual

$50

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

PPO

QHP/Non QHP

Both

Source Name

SERFF

Plan ID

10091OR0720001

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Oregon?

Dental PPO 0-20-50 1000 (10091OR0720001) is a High PPO from PacificSource Health Plans in Oregon for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Dental PPO 0-20-50 1000 support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Dental PPO 0-20-50 1000 HSA-eligible and does it include dental or vision coverage?

HSA eligibility is not published; check the Summary of Benefits or ask the issuer.

Dental add-ons: Adult, Child.

Vision coverage is not listed for this plan.

Does Dental PPO 0-20-50 1000 support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Is there out-of-country coverage for Dental PPO 0-20-50 1000?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Emergency care only

Does Dental PPO 0-20-50 1000 cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Non-participating providers

How do I enroll in or manage payments for Dental PPO 0-20-50 1000?

Use the issuer portal https://ipay.pacificsource.com/FFM/ to pay premiums or start enrollment, then return to HealthPorta for benefit comparisons.

Disclaimer: Based on the Tue, 10 Mar 2026 06:40 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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