Navigator Gold 3500 - 10091OR0710022 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 10091OR0710022. The plan is called Navigator Gold 3500.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.05% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.95% 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 79.70% (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 20.30% 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 | 10091OR0710022 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Health Insurance Plan Variant | 10091OR0710022-01 | ||||||||||||||||||
| Provider Network(s) | TIER-ONE | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Navigator Gold 3500 Health Insurance Plan Variant 10091OR0710022-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.796987576 |
| 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 | 79.05% |
| 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 | $3500 per person | $7000 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $3,500 |
| 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) | 10091OR0710022-01 |
| Plan Marketing Name | Navigator Gold 3500 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Navigator Gold 3500 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,700 |
| SBC Scenario, Having a Baby, Copayment | $25 |
| SBC Scenario, Having a Baby, Deductible | $3,500 |
| 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 | 10091OR0710022 |
| 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 3500 Health Insurance Plan, 10091OR0710022
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Navigator Gold 3500, 10091OR0710022 Health Insurance Plan, 10091OR0710022
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Does Navigator Gold 3500 Health Insurance Plan, 10091OR0710022 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (10091OR0710022) Health Insurance Plan, Variant (10091OR0710022-01) offer Disease Management Programs?
Does (10091OR0710022) Health Insurance Plan, Variant (10091OR0710022-01) have Out Of Country Coverage?
Does (10091OR0710022) Health Insurance Plan, Variant (10091OR0710022-01) have Out of Service Area Coverage?
Does (10091OR0710022) Health Insurance Plan, Variant (10091OR0710022-01) offer Disease Management Programs?
Does Navigator Gold 3500 Health Insurance Plan, Variant (10091OR0710022-01) offer Disease Management Programs for Asthma?
Does Navigator Gold 3500 Health Insurance Plan, Variant (10091OR0710022-01) offer Disease Management Programs for Heart disease?
Does Navigator Gold 3500 Health Insurance Plan, Variant (10091OR0710022-01) offer Disease Management Programs for Diabetes?
Does Navigator Gold 3500 Health Insurance Plan, Variant (10091OR0710022-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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