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, 10 Dec 2024 06:32 GMT).

Providers Oregon All US States
All 834 1632
PCP 1 2
Allergy N/A N/A
OB/GYN N/A N/A
Dentists 569 1141
Available Variants of the Health Plan

Standard Off Exchange Plan - 10091OR0720004-00

Standard On Exchange Plan - 10091OR0720004-01

Last Plan Update Date Thu, 01 Aug 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Dental PPO 0-20-50 1500 Health Insurance Plan, 10091OR0720004-00

Benefit Covered In Network Out Of Network
Accidental Dental
YES

50.00%

50.00% Coinsurance after deductible
Basic Dental Care - Adult

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.

YES

20.00%

20.00% Coinsurance after deductible
Basic Dental Care - Child

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.

YES

20.00%

20.00% Coinsurance after deductible
Dental Check-Up for Children

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.

YES

No Charge

20.00%
Major Dental Care - Adult

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

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.

YES

50.00%

50.00% Coinsurance after deductible
Major Dental Care - Child

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.

YES

50.00%

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child

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

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

YES

50.00%

50.00% Coinsurance after deductible
Routine Dental Services (Adult)

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

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.

YES

No Charge

20.00%

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

Frequently Asked Questions(FAQ) about Dental PPO 0-20-50 1500, 10091OR0720004 Health Insurance Plan, 10091OR0720004

  • 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?

    Yes. Details: Emergency care only

    Does (10091OR0720004) Health Insurance Plan, Variant (10091OR0720004-00) have Out of Service Area Coverage?

    Yes. Details: Non-participating providers

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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