PacificSource Health Plans health insurance plan with the Plan ID 10091OR0750011. The plan is called Navigator Catastrophic.
Health Insurance Plan ID | 10091OR0750011 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Oregon | ||||||||||||||||||
Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 10091OR0750011-00 | ||||||||||||||||||
Provider Network(s) | ['ORN005'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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Available Variants of the Health Plan | |||||||||||||||||||
Last Plan Update Date | Wed, 28 Sep 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
YES | No Charge |
No Charge |
Accidental Dental
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Acupuncture
Limit: 12.0 Visit(s) per Year Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Allergy Testing
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Chiropractic Care
Limit: 20.0 Visit(s) per Year Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Cosmetic Surgery
Limit: 1.0 Procedure(s) per Episode |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Dialysis
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Durable Medical Equipment
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Emergency Room Services
Exclusions: Charges for inpatient stays that began before you were covered by this plan. 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. |
YES | No Charge after deductible |
No Charge after deductible |
Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Gender Affirming Care
Information about gender affirming care can be found in plan documents. |
YES | ||
Generic Drugs
|
YES | No Charge after deductible |
90.00% Coinsurance after deductible |
Habilitation Services
Limit: 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Hearing Aids
Hearing assistance coverage complies with state and federal law. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Home Health Care Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Hospice Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Charges for inpatient stays that began before you were covered by this plan. 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. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Mental/Behavioral Health Outpatient Services
This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Non-Preferred Brand Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $80 max out of pocket for 30 day supply prior to deductible. See policy for more information. |
YES | No Charge after deductible |
90.00% Coinsurance after deductible |
Nutritional Counseling
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: Missed appointments and get acquainted visits. See policy for more information. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Preferred Brand Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $80 max out of pocket for 30 day supply prior to deductible. See policy for more information. |
YES | No Charge after deductible |
90.00% Coinsurance after deductible |
Prenatal and Postnatal Care
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Preventive Care/Screening/Immunization
|
YES | No Charge |
50.00% Coinsurance after deductible |
Primary Care Visit to Treat an Injury or Illness
Exclusions: Missed appointments and get acquainted visits. See policy for more information. First three office visits covered in full. Subsequent visits subject to deductible and coinsurance. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Radiation
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Reconstructive Surgery
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period Exclusions: Orthoptics, vision therapy, or other services to correct refractive error. Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. |
YES | No Charge |
50.00% Coinsurance after deductible |
Routine Foot Care
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Skilled Nursing Facility
Limit: 60.0 Days per Year Exclusions: Confinement for custodial care is not covered. See policy for more information. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Specialist Visit
Exclusions: Missed appointments and get acquainted visits. See policy for more information. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Specialty Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information. |
YES | No Charge after deductible |
90.00% Coinsurance after deductible |
Substance Abuse Disorder Inpatient Services
This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Substance Abuse Disorder Outpatient Services
This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Telehealth - Primary Care Visit
For services that are performed and billed as a true telemedicine visits, copays will be waived. HSA qualified plans will still be subject to the deductible and coinsurance. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Telehealth - Specialist Visit
For services that are performed and billed as a true telemedicine visits, copays will be waived. HSA qualified plans will still be subject to the deductible and coinsurance. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Transplant
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Treatment for Temporomandibular Joint Disorders
|
NO | ||
Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
50.00% Coinsurance after deductible |
X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
Plan Attribute | Value |
---|---|
Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Catastrophic Off Exchange Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
First Tier Utilization | 100% |
Formulary ID | ORF001 |
Formulary URL | URL |
HIOS Product ID | 10091OR075 |
Import Date | 9/28/2022 20:01 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | No |
New/Existing Plan | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 10091 |
Issuer Marketplace Marketing Name | PacificSource Health Plans |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Catastrophic |
Multiple In Network Tiers | No |
National Network | Yes |
Network ID | ORN005 |
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 | In and out-of-network providers |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 10091OR0750011-00 |
Plan Level Exclusions | No |
Plan Marketing Name | Navigator Catastrophic |
Plan Type | PPO |
Plan Variant Marketing Name | Navigator Catastrophic |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $9,100 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $5,200 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | ORS002 |
Source Name | SERFF |
Plan ID | 10091OR0750011 |
State Code | OR |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $18200 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9100 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,100 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $20000 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $10000 per person |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $10,000 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9100 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $50000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $25000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $25,000 |
Unique Plan Design | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | Yes |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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