Voyager Gold 1000 - 10091OR0710004 Health Insurance Plan

PacificSource Health Plans health insurance plan with the Plan ID 10091OR0710004. The plan is called Voyager Gold 1000.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.27% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.73% 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 81.65% (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 18.35% 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 10091OR0710004
Health Insurance Plan Year 2023
State Oregon
Health Insurance Issuer PacificSource Health Plans
Health Insurance Plan Variant 10091OR0710004-01
Provider Network(s) ['ORN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

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
Available Variants of the Health Plan

Standard On Exchange Plan - 10091OR0710004-01

Last Plan Update Date Mon, 23 Jan 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Voyager Gold 1000 Health Insurance Plan Variant 10091OR0710004-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.81650043
Business Year 2023
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 $0 per person | $0 per group
Drug EHB Deductible, Out of Network, Individual $0
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
First Tier Utilization 100%
Formulary ID ORF022
HIOS Product ID 10091OR071
Import Date 1/23/2023
HSA Eligible No
IsItANewPlan Existing
Notice Required for Pregnancy No
Issuer Actuarial Value 81.27%
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 $1000 per person | $2000 per group
Medical EHB Deductible, In Network (Tier 1), Individual $1,000
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 ORN001
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 10091OR0710004-01
Plan Marketing Name Voyager Gold 1000
Plan Type PPO
Plan Variant Marketing Name Voyager Gold 1000
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,500
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $1,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,100
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $300
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ORS001
Source Name SERFF
Plan ID 10091OR0710004
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 $7000 per person | $14000 per group
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 $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 Voyager Gold 1000 Health Insurance Plan, 10091OR0710004

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Voyager Gold 1000, 10091OR0710004 Health Insurance Plan, 10091OR0710004

  • Does Voyager Gold 1000 Health Insurance Plan, 10091OR0710004 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (10091OR0710004) Health Insurance Plan, Variant (10091OR0710004-01) offer Disease Management Programs?

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

    Does (10091OR0710004) Health Insurance Plan, Variant (10091OR0710004-01) have Out Of Country Coverage?

    Yes. Details: Emergency Care Services Only

    Does (10091OR0710004) Health Insurance Plan, Variant (10091OR0710004-01) have Out of Service Area Coverage?

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

    Does (10091OR0710004) Health Insurance Plan, Variant (10091OR0710004-01) offer Disease Management Programs?

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

    Does Voyager Gold 1000 Health Insurance Plan, Variant (10091OR0710004-01) offer Disease Management Programs for Asthma?

    Yes, the Voyager Gold 1000 Health Insurance Plan Variant 10091OR0710004-01 offers Disease Management Program for Asthma.

    Does Voyager Gold 1000 Health Insurance Plan, Variant (10091OR0710004-01) offer Disease Management Programs for Heart disease?

    Yes, the Voyager Gold 1000 Health Insurance Plan Variant 10091OR0710004-01 offers Disease Management Program for Heart disease.

    Does Voyager Gold 1000 Health Insurance Plan, Variant (10091OR0710004-01) offer Disease Management Programs for Diabetes?

    Yes, the Voyager Gold 1000 Health Insurance Plan Variant 10091OR0710004-01 offers Disease Management Program for Diabetes.

    Does Voyager Gold 1000 Health Insurance Plan, Variant (10091OR0710004-01) offer Disease Management Programs for Pregnancy?

    Yes, the Voyager Gold 1000 Health Insurance Plan Variant 10091OR0710004-01 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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