Oregon health plan · 2025

PacificSource Oregon Standard Gold Plan NAV · 10091OR0750014

PacificSource Health Plans offers this marketplace health insurance plan (Plan ID 10091OR0750014) 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.

Metal level: Gold Plan type: PPO CSR: Limited Cost Sharing Plan Variation Issuer: PacificSource Health Plans
Telehealth Data pending HSA eligible No Dental Not listed Vision Child
Pay / Manage Plan View issuer site

Issuer actuarial value: 81.91%. Expect to pay roughly 18.09% of covered costs out of pocket, based on issuer reporting.

CMS AV Calculator output: 81.09% (18.91% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$335 – $1838

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$7,000

$14000 per group

Review MOOP rules

Office visits

Primary care $20.00
Specialist $40.00
HSA Not eligible

Drug tiers

Generic $10.00
Preferred brand $30.00

View formulary tiers

$571 / mo before subsidies

≈ $6852 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1843 / mo before subsidies

≈ $22116 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$2140 / mo before subsidies

≈ $25680 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1508 / mo before subsidies

≈ $18096 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

20.00% Coinsurance after deductible

Durable Medical Equipment

20.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

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.
  • Limited Cost Sharing Plan Variation 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.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

20.00% Coinsurance after deductible

Durable Medical Equipment

20.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

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.

Plan ID 10091OR0750014
Coverage year 2025
State Oregon
Issuer PacificSource Health Plans
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 10091OR0750014-03
Available variants

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 Thu, 01 Aug 2024 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

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).

All providers in Oregon N/A
PCPs in Oregon N/A
Telehealth support Data pending
Nationwide providers N/A

Provider network(s)

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

Drug coverage overview

4,882 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
GENERIC 2,741
SPECIALTY 1,046
NON-PREFERRED-BRAND 792
ZERO-COST-SHARE-PREVENTIVE 303
Prior authorization Drugs
Required 1,387
Not Required 3,495
Step therapy Drugs
Required 105
Not Required 4,777
Quantity limits Drugs
Has Limit 1,439
No Limit 3,443

Customer highlights

What stands out for members

  • Issuer: PacificSource Health Plans · Plan ID 10091OR0750014 · 2025 filing.
  • Disease management programs available: Asthma, Diabetes, Heart Disease, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 10091OR0750014-03 (Open to Indians above 300% FPL) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

Limit: 20.0 Visit(s) per Year

nan

Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies.

Diabetes Education

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Home Health Care Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Laboratory Outpatient and Professional Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

$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.

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

Preventive Care/Screening/Immunization

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

$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.

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

Rehabilitative Occupational and Rehabilitative Physical Therapy

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Year

Visit limits do not apply to mental health conditions. See policy for more information.

Exclusions: nan

Rehabilitative Speech Therapy

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Year

Visit limits do not apply to mental health conditions. See policy for more information.

Exclusions: nan

Specialist Visit

$40.00
Tier 1 in-network $40.00
Out-of-network 50.00% Coinsurance after deductible

nan

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

Telehealth - Primary Care Visit

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

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.

Exclusions: nan

Telehealth - Specialist Visit

$40.00
Tier 1 in-network $40.00
Out-of-network 50.00% Coinsurance after deductible

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.

Exclusions: nan

Urgent Care Centers or Facilities

$60.00
Tier 1 in-network $60.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

X-rays and Diagnostic Imaging

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Zero Cost Share Preventive Drugs

No Charge
Tier 1 in-network No Charge
Out-of-network 90.00% Coinsurance after deductible

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

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Dialysis

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Durable Medical Equipment

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Emergency Room Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

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.

Exclusions: Charges for inpatient stays that began before you were covered by this plan.

Emergency Transportation/Ambulance

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Hospice Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Inpatient Hospital Services (e.g., Hospital Stay)

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Charges for a hospital room are covered up to the hospitals 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.

Exclusions: Charges for inpatient stays that began before you were covered by this plan.

Inpatient Physician and Surgical Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

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.

Exclusions: nan

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Outpatient Rehabilitation Services

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Year

Visit limits do not apply to mental health conditions. See policy for more information.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Radiation

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Skilled Nursing Facility

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 60.0 Days per Year

nan

Exclusions: Confinement for custodial care is not covered. See policy for more information.

Substance Abuse Disorder Inpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

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.

Exclusions: nan

Transplant

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Hearing assistance coverage complies with state and federal law.

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Eye Exam for Children

No Charge
Tier 1 in-network No Charge
Out-of-network No Charge

Limit: 1.0 Visit(s) per Benefit Period

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.

Exclusions: Orthoptics, vision therapy, or other services to correct refractive error.

Well Baby Visits and Care

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$10.00
Tier 1 in-network $10.00
Out-of-network 90.00% Coinsurance after deductible

nan

Exclusions: nan

Medical Service Drugs

Coverage details pending

nan

Exclusions: nan

Non-Preferred Brand Drugs

50.00%
Tier 1 in-network 50.00%
Out-of-network 90.00% Coinsurance after deductible

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.

Exclusions: nan

Preferred Brand Drugs

$30.00
Tier 1 in-network $30.00
Out-of-network 90.00% Coinsurance after deductible

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.

Exclusions: nan

Specialty Drugs

50.00%
Tier 1 in-network 50.00%
Out-of-network 90.00% Coinsurance after deductible

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.

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

nan

Exclusions: nan

Hormone Therapy

Coverage details pending

nan

Exclusions: nan

Infusion Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

No Charge
Tier 1 in-network No Charge
Out-of-network No Charge

nan

Exclusions: nan

Acupuncture

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

Limit: 12.0 Visit(s) per Year

nan

Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies.

Allergy Testing

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Bariatric Surgery

Coverage details pending

nan

Exclusions: nan

Cosmetic Surgery

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 1.0 Procedure(s) per Episode

nan

Exclusions: nan

Eye Glasses for Children

No Charge
Tier 1 in-network No Charge
Out-of-network No Charge

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.

Exclusions: nan

Gender Affirming Care

Coverage details pending

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.

Exclusions: nan

Habilitation Services

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Year

Visit limits do not apply to mental health conditions. See policy for more information.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Infertility Treatment

Coverage details pending

nan

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Non-Preferred Brand

50.00%
Tier 1 in-network 50.00%
Out-of-network 90.00% Coinsurance after deductible

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.

Exclusions: nan

Non-Preferred Generic

Coverage details pending

nan

Exclusions: nan

Preferred Brand

$30.00
Tier 1 in-network $30.00
Out-of-network 90.00% Coinsurance after deductible

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.

Exclusions: nan

Preferred Generic

$10.00
Tier 1 in-network $10.00
Out-of-network 90.00% Coinsurance after deductible

nan

Exclusions: nan

Private-Duty Nursing

Coverage details pending

nan

Exclusions: nan

Reconstructive Surgery

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Eye Exam (Adult)

Coverage details pending

nan

Exclusions: nan

Routine Foot Care

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

Coverage details pending

nan

Exclusions: nan

Variant attributes

PacificSource Oregon Standard Gold Plan NAV · Variant 10091OR0750014-03

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Limited Cost Sharing Plan Variation

HIOS Product ID

10091OR075

Metal Level

Gold

Plan ID (Standard Component ID with Variant)

10091OR0750014-03

Plan Marketing Name

PacificSource Oregon Standard Gold Plan NAV

Plan Variant Marketing Name

PacificSource Oregon Standard Gold Plan NAV (AI)

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

81.91%

Issuer ID

10091

Issuer Marketplace Marketing Name

PacificSource Health Plans

Market Coverage

Individual

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

Service Area ID

ORS002

State Code

OR

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.810889507054988

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

50.00%

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

No

Medical Drug Maximum Out of Pocket Integrated

Yes

Medical EHB Deductible, In Network (Tier 1), Default Coinsurance

20.00%

SBC Scenario, Having a Baby, Coinsurance

$0

SBC Scenario, Having a Baby, Copayment

$0

SBC Scenario, Having a Baby, Deductible

$0

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$0

SBC Scenario, Having Diabetes, Deductible

$0

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

$0

Specialty Drug Maximum Coinsurance

$500

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

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

ORF011

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

3

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

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), 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, Diabetes, Heart Disease, Pregnancy

EHB Percent of Total Premium

0.9999

First Tier Utilization

100%

Import Date

2024-08-01 20:01:31

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

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

$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

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

PPO

QHP/Non QHP

Both

Source Name

SERFF

Plan ID

10091OR0750014

Unique Plan Design

Yes

Wellness Program Offered

Yes

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?

PacificSource Oregon Standard Gold Plan NAV (10091OR0750014) is a Gold 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 PacificSource Oregon Standard Gold Plan NAV 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 PacificSource Oregon Standard Gold Plan NAV HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental coverage is not listed for this plan.

Vision add-ons: Child.

Does PacificSource Oregon Standard Gold Plan NAV support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with PacificSource Oregon Standard Gold Plan NAV?

The issuer lists disease management resources for: Asthma, Diabetes, Heart Disease, Pregnancy.

Is there out-of-country coverage for PacificSource Oregon Standard Gold Plan NAV?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Emergency Care Only

Does PacificSource Oregon Standard Gold Plan NAV 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: In and out-of-network providers

How do I enroll in or manage payments for PacificSource Oregon Standard Gold Plan NAV?

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.
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