Navigator Gold 2500 - 10091OR0710023 Health Insurance Plan

PacificSource Health Plans health insurance plan with the Plan ID 10091OR0710023. The plan is called Navigator Gold 2500.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.88% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.12% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.52% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.48% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 10091OR0710023
Health Insurance Plan Year 2024
State Oregon
Health Insurance Issuer PacificSource Health Plans
Health Insurance Plan Variant 10091OR0710023-01
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 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
Available Variants of the Health Plan

Standard On Exchange Plan - 10091OR0710023-01

Last Plan Update Date Mon, 12 Feb 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Navigator Gold 2500 Health Insurance Plan Variant 10091OR0710023-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.805196747
Begin Primary Care Cost-Sharing After Number Of Visits 3
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered Yes
CSR Variation Type Standard Gold On Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family per person not applicable | per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Drug EHB Deductible, In Network (Tier 1), Family $0 per person | $0 per group
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family $5000 per person | $10000 per group
Drug EHB Deductible, Out of Network, Individual $5,000
Dental Only Plan No
Disease Management Programs Offered Pregnancy, Diabetes, Heart Disease, Asthma
First Tier Utilization 100%
Formulary ID ORF022
HIOS Product ID 10091OR071
HSA/HRA Employer Contribution No
Import Date 2/12/2024
HSA Eligible No
IsItANewPlan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 79.88%
Issuer ID 10091
Market Coverage SHOP (Small Group)
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family per person not applicable | per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Medical EHB Deductible, In Network (Tier 1), Family $2500 per person | $5000 per group
Medical EHB Deductible, In Network (Tier 1), Individual $2,500
Medical EHB Deductible, Out of Network, Family $5000 per person | $10000 per group
Medical EHB Deductible, Out of Network, Individual $5,000
Metal Level Gold
Multiple In Network Tiers No
National Network Yes
Network ID ORN002
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Care Services Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description In and out-of-network providers
Plan Effective Date 1/1/2024
Plan Expiration Date 12/31/2024
Plan ID (Standard Component ID with Variant) 10091OR0710023-01
Plan Marketing Name Navigator Gold 2500
Plan Type PPO
Plan Variant Marketing Name Navigator Gold 2500
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,000
SBC Scenario, Having a Baby, Copayment $25
SBC Scenario, Having a Baby, Deductible $2,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,015
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $30
SBC Scenario, Treatment of a Simple Fracture, Copayment $315
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ORS003
Source Name SERFF
Plan ID 10091OR0710023
State Code OR
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family per person not applicable | per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family $6500 per person | $13000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family $7500 per person | $15000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $7,500
Unique Plan Design Yes
Version Number 1
Wellness Program Offered Yes

Copay & Coinsurance of Navigator Gold 2500 Health Insurance Plan, 10091OR0710023

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Navigator Gold 2500, 10091OR0710023 Health Insurance Plan, 10091OR0710023

  • Does Navigator Gold 2500 Health Insurance Plan, 10091OR0710023 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (10091OR0710023) Health Insurance Plan, Variant (10091OR0710023-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Pregnancy, Diabetes, Heart Disease, Asthma

    Does (10091OR0710023) Health Insurance Plan, Variant (10091OR0710023-01) have Out Of Country Coverage?

    Yes. Details: Emergency Care Services Only

    Does (10091OR0710023) Health Insurance Plan, Variant (10091OR0710023-01) have Out of Service Area Coverage?

    Yes. Details: In and out-of-network providers

    Does (10091OR0710023) Health Insurance Plan, Variant (10091OR0710023-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Pregnancy, Diabetes, Heart Disease, Asthma

    Does Navigator Gold 2500 Health Insurance Plan, Variant (10091OR0710023-01) offer Disease Management Programs for Asthma?

    Yes, the Navigator Gold 2500 Health Insurance Plan Variant 10091OR0710023-01 offers Disease Management Program for Asthma.

    Does Navigator Gold 2500 Health Insurance Plan, Variant (10091OR0710023-01) offer Disease Management Programs for Heart disease?

    Yes, the Navigator Gold 2500 Health Insurance Plan Variant 10091OR0710023-01 offers Disease Management Program for Heart disease.

    Does Navigator Gold 2500 Health Insurance Plan, Variant (10091OR0710023-01) offer Disease Management Programs for Diabetes?

    Yes, the Navigator Gold 2500 Health Insurance Plan Variant 10091OR0710023-01 offers Disease Management Program for Diabetes.

    Does Navigator Gold 2500 Health Insurance Plan, Variant (10091OR0710023-01) offer Disease Management Programs for Pregnancy?

    Yes, the Navigator Gold 2500 Health Insurance Plan Variant 10091OR0710023-01 offers Disease Management Program for Pregnancy.

 

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