Begin Primary Care Cost-Sharing After Number Of Visits
0
Child-Only Offering
Allows Adult and Child-Only
Composite Rating Offered
No
Disease Management Programs Offered
Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium
1.0
First Tier Utilization
100%
Import Date
2024-09-26 03:01:39
Limited Cost Sharing Plan Variation - Estimated Advanced Payment
$0.00
New/Existing Plan
Existing
Notice Required for Pregnancy
Yes
Is a Referral Required for Specialist?
Yes
Plan Effective Date
2025-01-01
Plan Expiration Date
2025-12-31
Plan Level Exclusions
Prior Authorization, Medically Necessary/Medical Necessity, Act of War, Ongoing Medical Necessity, Experimental/ Investigational Treatment, Service Before Effective Date, Service After Termination Date, Services While Incarcerated, Any Charge for an Appointment a Member does not Attend, Services for Injuries Incurred During the Commission of a Crime
Specialist Requiring a Referral
Allergy, Asthma, Audiology, Cardiovascular, Dermatology, ENT/Otolaryngology, Endocrinology, Gastroenterology, General Surgery, Geriatrics, Hematology, Immunology, Infectious Diseases, Nephrology, Neurology , Neurosurgery, Medical Oncology, Ophthalmology, Orthopedics, Pain Management, Peripheral Vascular, Perinatology, Plastic Surgery, Pulmonology, Radiation Oncology, Rheumatology, Speech Therapy, Spine Medicine, Sports Medicine, Transplant Surgery/Medicine, Urology, Vascular Surgery, All out of area specialty care
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group
per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person
per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual
Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group
$0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person
$0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual
$0
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group
per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person
per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual
Not Applicable
Wellness Program Offered
No