Bronze Standard Rx Copay - 66699CO0030009 Health Insurance Plan
Denver Health Medical Plan, Inc. health insurance plan with the Plan ID 66699CO0030009. The plan is called Bronze Standard Rx Copay.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 60.93% (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 39.07% 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 | 66699CO0030009 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Colorado | ||||||||||||||||||
| Health Insurance Issuer | Denver Health Medical Plan, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 66699CO0030009-01 | ||||||||||||||||||
| Provider Network(s) | ['CON001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 66699CO0030009-01 |
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| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Bronze Standard Rx Copay Health Insurance Plan Variant 66699CO0030009-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.609250382 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 100% |
| Formulary ID | COF006 |
| HIOS Product ID | 66699CO003 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 66699 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | CON001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Hospital Emergency Room, Urgent Care |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 66699CO0030009-01 |
| Plan Marketing Name | Bronze Standard Rx Copay |
| Plan Type | HMO |
| Plan Variant Marketing Name | Bronze Standard Rx Copay |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $8,550 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,500 |
| SBC Scenario, Having Diabetes, Deductible | $1,900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | COS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All Except for OB GYN, Outpatient Behavioral Health and Routine Eye Care |
| Plan ID | 66699CO0030009 |
| State Code | CO |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group 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), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $8550 per person | $17100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,550 |
| TEHBDedOutofNetFamily | per person not applicable | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $8550 per person | $17100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,550 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Bronze Standard Rx Copay Health Insurance Plan, 66699CO0030009
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Bronze Standard Rx Copay, 66699CO0030009 Health Insurance Plan, 66699CO0030009
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Does Bronze Standard Rx Copay Health Insurance Plan, 66699CO0030009 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (66699CO0030009) Health Insurance Plan, Variant (66699CO0030009-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (66699CO0030009) Health Insurance Plan, Variant (66699CO0030009-01) have Out of Service Area Coverage?
Yes. Details: Hospital Emergency Room, Urgent Care
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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