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 data of Health Plan Issuer, this plan has an actuarial value of 81.91% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.09% 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 81.09% (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 18.91% 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
Health Insurance Plan Year 2025
State Oregon
Health Insurance Issuer PacificSource Health Plans
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 10091OR0750014-01
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 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 - 10091OR0750014-00

Standard On Exchange Plan - 10091OR0750014-01

Open to Indians below 300% FPL - 10091OR0750014-02

Open to Indians above 300% FPL - 10091OR0750014-03

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

Benefits of PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, 10091OR0750014-01

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

No Charge

No Charge
Accidental Dental
YES

20.00% Coinsurance 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

$20.00

50.00% Coinsurance after deductible
Allergy Testing
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

20.00% Coinsurance 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

$20.00

50.00% Coinsurance after deductible
Cosmetic Surgery

Limit: 1.0 Procedure(s) per Episode

YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge

50.00% Coinsurance after deductible
Dialysis
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

20.00% Coinsurance 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

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

No charge up to $150 maximum then subject to medical deductible and coinsurance. See policy for more information.

YES

No Charge

No Charge
Gender Affirming Care

Gender affirming care is covered when determined by a provider as medically necessary and follows accepted standards of care. Please check with the insurance carrier for coverage information, including any limitations and exclusions.

YES
Generic Drugs
YES

$10.00

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

$20.00

50.00% Coinsurance after deductible
Hearing Aids

Hearing assistance coverage complies with state and federal law.

YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Home Health Care Services
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hormone Therapy
YES
Hospice Services
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

20.00% Coinsurance 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

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Medical Service Drugs
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

20.00% Coinsurance 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. $5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

YES

$20.00

50.00% Coinsurance after deductible
Non-Preferred Brand

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $35 max out of pocket for 30 day supply prior to deductible. See policy for more information.

YES

50.00%

90.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $35 max out of pocket for 30 day supply prior to deductible. See policy for more information.

YES

50.00%

90.00% Coinsurance after deductible
Non-Preferred Generic
NO
Nutritional Counseling
YES

No Charge

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.

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

YES

$20.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

20.00% Coinsurance 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

$20.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $35 max out of pocket for 30 day supply prior to deductible. See policy for more information.

YES

$30.00

90.00% Coinsurance after deductible
Preferred Brand Drugs

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $35 max out of pocket for 30 day supply prior to deductible. See policy for more information.

YES

$30.00

90.00% Coinsurance after deductible
Preferred Generic
YES

$10.00

90.00% Coinsurance after deductible
Prenatal and Postnatal Care
YES

20.00% Coinsurance 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.

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

YES

$20.00

50.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery
YES

20.00% Coinsurance 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

$20.00

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

$20.00

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. In network: Covered in Full. Out of network: No charge up to $40 maximum, and the remaining cost is member responsibility.

YES

No Charge

No Charge
Routine Foot Care
YES

20.00% Coinsurance 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

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit

Exclusions: Missed appointments and get acquainted visits. See policy for more information.

YES

$40.00

50.00% Coinsurance after deductible
Specialty Drugs

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. $500 cap per script for Standard Gold Plans. See policy for more information.

YES

50.00%

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

20.00% Coinsurance 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. $5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

YES

$20.00

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. $5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

YES

$20.00

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

$40.00

50.00% Coinsurance after deductible
Transplant
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$60.00

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

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Zero Cost Share Preventive Drugs

Limited to Affordable Care Act Standard Preventive No-cost Drug List

YES

No Charge

90.00% Coinsurance after deductible

PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant 10091OR0750014-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.8108895070549879
Begin Primary Care Cost-Sharing After Number Of Visits 3
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 Gold On 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 $20000 per group
Drug EHB Deductible, Out of Network, Family Per Person $10000 per person
Drug EHB Deductible, Out of Network, Individual $10,000
Dental Only Plan No
Design Type Design 3
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9999
First Tier Utilization 100%
Formulary ID ORF011
Formulary URL URL
HIOS Product ID 10091OR075
Import Date 2024-08-01 20:01:31
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 Actuarial Value 81.91%
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 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 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 10091OR0750014-01
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 $10
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 ORS002
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 $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,000
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 Yes
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

Frequently Asked Questions(FAQ) about PacificSource Oregon Standard Gold Plan NAV, 10091OR0750014 Health Insurance Plan, 10091OR0750014

  • 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 (10091OR0750014-01) offer Disease Management Programs?

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

    Does (10091OR0750014) Health Insurance Plan, Variant (10091OR0750014-01) have Out Of Country Coverage?

    Yes. Details: Emergency Care Only

    Does (10091OR0750014) Health Insurance Plan, Variant (10091OR0750014-01) have Out of Service Area Coverage?

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

    Does (10091OR0750014) Health Insurance Plan, Variant (10091OR0750014-01) 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 (10091OR0750014-01) offer Disease Management Programs for Asthma?

    Yes, the PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant 10091OR0750014-01 offers Disease Management Program for Asthma.

    Does PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, Variant (10091OR0750014-01) offer Disease Management Programs for Heart disease?

    Yes, the PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant 10091OR0750014-01 offers Disease Management Program for Heart disease.

    Does PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, Variant (10091OR0750014-01) offer Disease Management Programs for Diabetes?

    Yes, the PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant 10091OR0750014-01 offers Disease Management Program for Diabetes.

    Does PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan, Variant (10091OR0750014-01) offer Disease Management Programs for Pregnancy?

    Yes, the PacificSource Oregon Standard Gold Plan NAV Health Insurance Plan Variant 10091OR0750014-01 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