Providence Oregon Standard Gold Plan - Signature Network - 56707OR1350004 Health Insurance Plan
Providence Health Plan health insurance plan with the Plan ID 56707OR1350004. The plan is called Providence Oregon Standard Gold Plan - Signature Network.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.22% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.78% 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 81.99% (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 18.01% 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 | 56707OR1350004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | Providence Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 56707OR1350004-01 | ||||||||||||||||||
| Provider Network(s) | EPO | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 18 Feb 2025 06:10 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 56707OR1350004-00 Standard On Exchange Plan - 56707OR1350004-01 |
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| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 18 Feb 2025 06:10 GMT |
Benefits of Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, 56707OR1350004-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Limit: 12.0 Visit(s) per Year |
YES | $20.00 |
100.00% |
| Allergy Testing
Other medically necessary diagnostic services provided in a hospital or outpatient setting, including testing or observation to diagnose the extent of a medical condition. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | $20.00 |
100.00% |
| Cosmetic Surgery
Benefit is limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
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
|
YES | No Charge |
100.00% |
| 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
Limit: 30.0 Days per Month Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions. |
YES | $20.00 |
100.00% |
| Hearing Aids
One hearing aid per hearing impaired ear if prescribed, fitted, and dispensed by a licensed audiologist with the approval of a licensed physician. Coverage will be provided every 36 months as medically necessary for the treatment of a member's hearing loss. |
YES | 20.00% |
100.00% |
| Home Health Care Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hormone Therapy
|
YES | ||
| Hospice Services
Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| 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
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
$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 |
100.00% |
| Non-Preferred Brand
Limit: 30.0 Days per Month Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | 50.00% |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | 50.00% |
100.00% |
| Non-Preferred Generic
Limit: 30.0 Days per Month Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | $30.00 |
100.00% |
| Nutritional Counseling
|
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
$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. Practitioners assisting specialists will be charged at the specialist copay. |
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions. |
YES | $20.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preferred Brand
Limit: 30.0 Days per Month Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | $30.00 |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | $30.00 |
100.00% |
| Preferred Generic
Limit: 30.0 Days per Month Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | $10.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
$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 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions. |
YES | $20.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions. |
YES | $20.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
|
YES | No Charge |
100.00% |
| Routine Foot Care
Benefit is limited to persons being treated for diabetes mellitus |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $40.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month $500 cap per prescription for the Standard Gold Plan. Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
$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 |
100.00% |
| Telehealth - Primary Care
ExpressCare Virtual No Charge |
YES | $20.00 |
100.00% |
| Telehealth - Specialist
|
YES | $40.00 |
100.00% |
| Transplant
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $60.00 |
$60.00 Copay after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Zero Cost Share Preventive Drugs
Limit: 30.0 Days per Month |
YES | No Charge |
100.00% |
Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan Variant 56707OR1350004-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.819894251215163 |
| 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 | 0.00% |
| 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 | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Design 3 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9994 |
| First Tier Utilization | 100% |
| Formulary ID | ORF003 |
| Formulary URL | URL |
| HIOS Product ID | 56707OR135 |
| Import Date | 2024-08-14 20:01:41 |
| 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 | 81.22% |
| Issuer ID | 56707 |
| Issuer Marketplace Marketing Name | Providence Health Plan |
| 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 | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | ORN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Care and Urgent Care no network; all other services National Network |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 56707OR1350004-01 |
| Plan Marketing Name | Providence Oregon Standard Gold Plan - Signature Network |
| Plan Type | EPO |
| Plan Variant Marketing Name | Providence Oregon Standard Gold Plan - Signature Network |
| 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 | $800 |
| 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 | ORS001 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $500 |
| Plan ID | 56707OR1350004 |
| 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 | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, 56707OR1350004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Providence Oregon Standard Gold Plan - Signature Network, 56707OR1350004 Health Insurance Plan, 56707OR1350004
-
Does Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, 56707OR1350004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (56707OR1350004) Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs?
Does (56707OR1350004) Health Insurance Plan, Variant (56707OR1350004-01) have Out Of Country Coverage?
Does (56707OR1350004) Health Insurance Plan, Variant (56707OR1350004-01) have Out of Service Area Coverage?
Does (56707OR1350004) Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs?
Does Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs for Asthma?
Does Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs for Heart disease?
Does Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs for Depression?
Does Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs for Diabetes?
Does Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs for Low back pain?
Does Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs for Pregnancy?
Does Providence Oregon Standard Gold Plan - Signature Network Health Insurance Plan, Variant (56707OR1350004-01) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 18 Feb 2025 06:10 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