Dental PPO 0-20-50 1500 - 10091OR0720004 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 10091OR0720004. The plan is called Dental PPO 0-20-50 1500.
| Health Insurance Plan ID | 10091OR0720004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 10091OR0720004-00 | ||||||||||||||||||
| Provider Network(s) | TIER-ONE | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 13 May 2025 06:05 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 01 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 13 May 2025 06:05 GMT |
Dental PPO 0-20-50 1500 Health Insurance Plan Variant 10091OR0720004-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1.0 |
| First Tier Utilization | 100% |
| HIOS Product ID | 10091OR072 |
| Import Date | 2024-08-01 20:01:31 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 10091 |
| Issuer Marketplace Marketing Name | PacificSource Health Plans |
| Market Coverage | Individual |
| 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 |
| 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 |
| 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 |
| Metal Level | High |
| 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 |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 10091OR0720004-00 |
| Plan Marketing Name | Dental PPO 0-20-50 1500 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Dental PPO 0-20-50 1500 |
| QHP/Non QHP | Both |
| Service Area ID | ORS004 |
| Source Name | SERFF |
| Plan ID | 10091OR0720004 |
| State Code | OR |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of Dental PPO 0-20-50 1500 Health Insurance Plan, 10091OR0720004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Dental PPO 0-20-50 1500, 10091OR0720004 Health Insurance Plan, 10091OR0720004
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Does Dental PPO 0-20-50 1500 Health Insurance Plan, 10091OR0720004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (10091OR0720004) Health Insurance Plan, Variant (10091OR0720004-00) have Out Of Country Coverage?
Does (10091OR0720004) Health Insurance Plan, Variant (10091OR0720004-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 13 May 2025 06:05 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API