PacificSource Health Plans offers this marketplace health insurance plan (Plan ID 10091OR0720004) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.
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 On 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.
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.
Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).
Variant 10091OR0720004-01 (Standard On 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-network20.00%
Out-of-network20.00% 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-network50.00%
Out-of-network50.00% 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.
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-networkNo Charge
Out-of-network20.00%
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-network50.00%
Out-of-network50.00% 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-network50.00%
Out-of-network50.00% 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-networkNo Charge
Out-of-network20.00%
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.
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
10091OR0720004
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 1500 (10091OR0720004) 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 1500 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 1500 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 1500 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 1500?
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 1500 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 1500?
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, 02 Dec 2025 06:13 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.
