PacificSource Oregon Standard Gold Plan NAV - 10091OR0750014 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 10091OR0750014. The plan is called PacificSource Oregon Standard Gold Plan NAV.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.94% (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 18.06% 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 | 10091OR0750014 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 10091OR0750014-00 | ||||||||||||||||||
| Provider Network(s) | ['ORN002'] | ||||||||||||||||||
| 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 | Standard Off Exchange Plan - 10091OR0750014-00 Standard On Exchange Plan - 10091OR0750014-01 |
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| Last Plan Update Date | Wed, 01 Sep 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant 10091OR0750014-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.819369344 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Drug EHB Deductible, Out of Network, Individual | $0 |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9999 |
| First Tier Utilization | 100% |
| Formulary ID | ORF013 |
| Formulary URL | URL |
| HIOS Product ID | 10091OR075 |
| Import Date | 9/1/2021 21:01 |
| 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 | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| 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), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Medical EHB Deductible, Out of Network, Family Per Group | $20000 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $10000 per person |
| Medical EHB Deductible, Out of Network, Individual | $10,000 |
| 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 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 | 1/1/2022 |
| Plan ID (Standard Component ID with Variant) | 10091OR0750014-00 |
| Plan Marketing Name | PacificSource Oregon Standard Gold Plan NAV |
| Plan Type | PPO |
| Plan Variant Marketing Name | PacificSource Oregon Standard Gold Plan NAV |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,200 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ORS004 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $500 |
| Plan ID | 10091OR0750014 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7300 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,300 |
| 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 |
Copay & Coinsurance of PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, 10091OR0750014
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about PacificSource Oregon Standard Gold Plan NAV, 10091OR0750014 Health Insurance Plan, 10091OR0750014
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Does PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, 10091OR0750014 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (10091OR0750014) Health Insurance Plan, Variant (10091OR0750014-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does (10091OR0750014) Health Insurance Plan, Variant (10091OR0750014-00) have Out Of Country Coverage?
Yes. Details: Emergency Care Only
Does (10091OR0750014) Health Insurance Plan, Variant (10091OR0750014-00) have Out of Service Area Coverage?
Yes. Details: In and out-of-network providers
Does (10091OR0750014) Health Insurance Plan, Variant (10091OR0750014-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, Variant (10091OR0750014-00) offer Disease Management Programs for Asthma?
Yes, the PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant
10091OR0750014-00 offers Disease
Management Program for Asthma.
Does PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, Variant (10091OR0750014-00) offer Disease Management Programs for Heart disease?
Yes, the PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant
10091OR0750014-00 offers Disease
Management Program for Heart disease.
Does PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, Variant (10091OR0750014-00) offer Disease Management Programs for Diabetes?
Yes, the PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant
10091OR0750014-00 offers Disease
Management Program for Diabetes.
Does PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, Variant (10091OR0750014-00) offer Disease Management Programs for Pregnancy?
Yes, the PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant
10091OR0750014-00 offers Disease
Management Program for Pregnancy.
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