Catastrophic Standard - 68445AZ0590050 Health Insurance Plan

Antidote Health Plan of Arizona, Inc. health insurance plan with the Plan ID 68445AZ0590050. The plan is called Catastrophic Standard.

Health Insurance Plan ID 68445AZ0590050
Health Insurance Plan Year 2025
State Arizona
Health Insurance Issuer Antidote Health Plan of Arizona, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 68445AZ0590050-00
Provider Network(s) TIERONE
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Arizona All US States
All 4033 151884
PCP 1 115
Allergy N/A N/A
OB/GYN N/A 1
Dentists 1995 64107
Available Variants of the Health Plan

Standard Off Exchange Plan - 68445AZ0590050-00

Standard On Exchange Plan - 68445AZ0590050-01

Last Plan Update Date Fri, 11 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Catastrophic Standard Health Insurance Plan, 68445AZ0590050-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.

YES

0% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

0% Coinsurance after deductible

100.00%
Bariatric Surgery

1. The patient must have a body-mass index (BMI) greather than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record: Active participation within the last two years in one physician-supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components:a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. In addition, the procedure must be performed at an approved Center of Excellence facility that is credentialed by your Health Network to perform bariatric surgery.; 5. The member must be 18 years or older, or have reached full expected skeletal growth.

YES

0% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Coverage includes benefits specified in the detailed in plan document.

YES

0% Coinsurance after deductible

100.00%
Chemotherapy
YES

0% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits.

YES

0% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship.

YES

0% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Exam(s) per 6 Months

YES

0% Coinsurance after deductible

100.00%
Diabetes Education
YES

0% Coinsurance after deductible

100.00%
Dialysis
YES

0% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

0% Coinsurance after deductible

100.00%
Emergency Room Services
YES

0% Coinsurance after deductible

100.00%
Emergency Transportation/Ambulance
YES

0% Coinsurance after deductible

100.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

0.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. Complete plans offer an expanded $0 drug list.

YES

0% Coinsurance after deductible

100.00%
Habilitation Services

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

YES

0% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per Benefit Period

Hearing aid devices limited to one per ear, per Plan Year when determined to be medically necessary by the Medical Management Organization.

YES

0% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 42.0 Visit(s) per Year

1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary by the Medical Management Organization.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.

YES

0% Coinsurance after deductible

100.00%
Hospice Services

The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.

YES

0% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

0% Coinsurance after deductible

100.00%
Infertility Treatment

Coverage of diagnosis and treatment of the underlying causes of infertility when provided by or under the direction of a Network Provider.

YES

0% Coinsurance after deductible

100.00%
Infusion Therapy

Infusion/IV Therapy in an Outpatient setting including, but not limited to: Inflixima/b (Remicade), Alefacept (Amevive), and Etanercept (Enbrel).

YES

0% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

0% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

0% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

0% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Coverage includes benefits specified in the detailed in plan document.

YES

0% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

0% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

0% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. Complete plans offer an expanded $0 drug list.

YES

0% Coinsurance after deductible

100.00%
Nutritional Counseling

Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to:1. Morbid obesity 2. Diabetes3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia

YES

0% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Coverage includes benefits specified in the detailed in plan document.

YES

0% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

0% Coinsurance after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

0% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Short-term rehabilitative therapy includes services in an outpatient facility or physician's office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined.

YES

0% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

0% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. Complete plans offer an expanded $0 drug list.

YES

0% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

0% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

Limit: 1.0 Exam(s) per Year

Well Woman and Well Man examinations are limited to 1 visit per year.

YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

0% Coinsurance after deductible

100.00%
Private-Duty Nursing

Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan.

YES

0% Coinsurance after deductible

100.00%
Prosthetic Devices

The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year and $150 maximum. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear.

YES

0% Coinsurance after deductible

100.00%
Radiation
YES

0% Coinsurance after deductible

100.00%
Reconstructive Surgery

Following a mastectomy, the following services and supplies are covered:1. Surgical services for reconstruction of the breast on which the mastectomy was performed;2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance;3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs.During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. Congenital defects and birth abnormalities are covered for Eligible Dependent children.

YES

0% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST).

YES

0% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST).

YES

0% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

0.00% Coinsurance after deductible

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Year

YES

0% Coinsurance after deductible

100.00%
Specialist Visit
YES

0% Coinsurance after deductible

100.00%
Specialty Drugs

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. Complete plans offer an expanded $0 drug list.

YES

0% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

0% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

0% Coinsurance after deductible

100.00%
Transplant

Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient's medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:1. Allogeneic bone marrow/stem cell;2. Autologous bone marrow/stem cell;3. Cornea;4. Heart;5. Heart/lung;6. Kidney;7. Kidney/pancreas;8. Liver;9. Lung;10. Pancreas;11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.

YES

0% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of: 1. An accident; 2. Trauma; 3. A congenital defect; 4. A developmental defect; or 5. A pathology.

YES

0% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

0% Coinsurance after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.

YES

0.00% Coinsurance after deductible

100.00%
X-rays and Diagnostic Imaging
YES

0% Coinsurance after deductible

100.00%

Catastrophic Standard Health Insurance Plan Variant 68445AZ0590050-00 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 3
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Catastrophic Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID AZF007
Formulary URL URL
HIOS Product ID 68445AZ059
Import Date 2024-10-11 01:02:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 68445
Issuer Marketplace Marketing Name Antidote Health Plan of Arizona, Inc.
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Catastrophic
Multiple In Network Tiers No
National Network No
Network ID AZN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 68445AZ0590050-00
Plan Marketing Name Catastrophic Standard
Plan Type HMO
Plan Variant Marketing Name Catastrophic Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,200
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID AZS001
Source Name HIOS
Plan ID 68445AZ0590050
State Code AZ
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
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), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $18400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,200
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $18400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,200
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Catastrophic Standard Health Insurance Plan, 68445AZ0590050

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

Frequently Asked Questions(FAQ) about Catastrophic Standard, 68445AZ0590050 Health Insurance Plan, 68445AZ0590050

  • Does Catastrophic Standard Health Insurance Plan, 68445AZ0590050 support Mail Ordering?

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

  • Does (68445AZ0590050) Health Insurance Plan, Variant (68445AZ0590050-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (68445AZ0590050) Health Insurance Plan, Variant (68445AZ0590050-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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