Elite Gold + Vision + Adult Dental - 91450AZ0180113 Health Insurance Plan
Health Net of Arizona, Inc. health insurance plan with the Plan ID 91450AZ0180113. The plan is called Elite Gold + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.80% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.20% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 91450AZ0180113 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arizona | ||||||||||||||||||
| Health Insurance Issuer | Health Net of Arizona, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 91450AZ0180113-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Sep 2025 15:17 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 91450AZ0180113-00 Standard On Exchange Plan - 91450AZ0180113-01 |
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| Last Plan Update Date | Thu, 15 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Sep 2025 15:17 GMT |
Benefits of Elite Gold + Vision + Adult Dental Health Insurance Plan, 91450AZ0180113-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Bariatric Surgery
Exclusions: nan 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 physiciansupervised 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 | 30.00% |
100.00% |
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year Exclusions: nan $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Exclusions: nan HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits. |
YES | $60.00 |
100.00% |
| Clinical Trials
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Care Management
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Diabetes Education
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | 30.00% |
30.00% |
| Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | 30.00% |
30.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan nan |
YES | No Charge |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Generic Drugs
Exclusions: nan Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | $3.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: nan Limited to 60 visits per year (combined for outpatient physical, speech, occupational, cardiac and pulmonary therapy). |
YES | $50.00 |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per Year Exclusions: nan Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit. |
YES | 30.00% |
100.00% |
| Home Health Care Services
Limit: 42.0 Visit(s) per Year Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Hospice Services
Exclusions: Respite Care is not a covered benefit. nan |
YES | 30.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | $75.00 |
100.00% |
| Infertility Treatment
Exclusions: nan Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Inherited Metabolic Disorder - PKU
Exclusions: nan nan |
YES | $40.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | $40.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit. |
NO | ||
| Major Dental Care - Adult
Limit: 1000.0 Dollars per Year Exclusions: nan $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Emergency Room
Exclusions: nan nan |
YES | 30.00% |
30.00% |
| Mental/Behavioral Health Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | 30.00% |
30.00% |
| Mental/Behavioral Health ER Physician Fee
Exclusions: nan nan |
YES | 30.00% |
30.00% |
| Mental/Behavioral Health Inpatient Services
Exclusions: nan Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $5.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
Exclusions: nan nan |
YES | $35.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | 45.00% |
100.00% |
| Nutritional Counseling
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Off Label Prescription Drugs
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $5.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: nan Limited to 60 visits per year (combined for outpatient physical, speech, occupational, cardiac and pulmonary therapy). Note: This visit limit does not apply when treatment is provided for a mental health/substance use disorder diagnosis. |
YES | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | $5.00 |
100.00% |
| Prescription Drugs Other
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Unlimited Virtual 24/7 Care Visits received from Ambetters designated telehealth provider covered at No Charge, except for HSAs. |
YES | $5.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Prosthetic Devices
Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Radiation
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Reconstructive Surgery
Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Exclusions: nan Limited to 60 visits per year (combined for outpatient physical, speech, occupational, cardiac and pulmonary therapy). Note: This visit limit does not apply when treatment is provided for a mental health/substance use disorder diagnosis. |
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Exclusions: nan Limited to 60 visits per year (combined for outpatient physical, speech, occupational, cardiac and pulmonary therapy). Note: This visit limit does not apply when treatment is provided for a mental health/substance use disorder diagnosis. |
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
Limit: 1000.0 Dollars per Year Exclusions: nan $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year Exclusions: nan Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses. |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: nan nan |
YES | No Charge |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Skilled Nursing Facility
Limit: 90.0 Days per Year Exclusions: nan nan |
YES | 30.00% |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Specialty Drugs
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $5.00 |
100.00% |
| Substance Use Disorder Emergency Room
Exclusions: nan nan |
YES | 30.00% |
30.00% |
| Substance Use Disorder Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | 30.00% |
30.00% |
| Substance Use Disorder ER Physician Fee
Exclusions: nan nan |
YES | 30.00% |
30.00% |
| Substance Use Disorder Outpatient Other Services
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Substance Use Disorder Urgent Care
Exclusions: nan nan |
YES | $35.00 |
100.00% |
| Tier 1b Generic Drugs
Exclusions: nan Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | $15.00 |
100.00% |
| Transplant
Exclusions: nan Limited to $10,000 for transportation & lodging per transplant. |
YES | 30.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | $200.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $35.00 |
100.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| Wigs
Exclusions: nan nan |
YES | 30.00% |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | $75.00 |
100.00% |
Elite Gold + Vision + Adult Dental Health Insurance Plan Variant 91450AZ0180113-01 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| 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 |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Diabetes, Heart Disease, Pregnancy |
| EHB Percent of Total Premium | 0.9611 |
| First Tier Utilization | 100% |
| Formulary ID | AZF005 |
| Formulary URL | URL |
| HIOS Product ID | 91450AZ018 |
| Import Date | 2024-08-15 01:01:23 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.80% |
| Issuer ID | 91450 |
| Issuer Marketplace Marketing Name | Ambetter from Arizona Complete Health |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| 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 ID (Standard Component ID with Variant) | 91450AZ0180113-01 |
| Plan Marketing Name | Elite Gold + Vision + Adult Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | Elite Gold + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $200 |
| SBC Scenario, Having Diabetes, Copayment | $1,100 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | AZS001 |
| Source Name | HIOS |
| Plan ID | 91450AZ0180113 |
| 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 | 30.00% |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $11000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,500 |
| 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 | No |
Copay & Coinsurance of Elite Gold + Vision + Adult Dental Health Insurance Plan, 91450AZ0180113
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Elite Gold + Vision + Adult Dental, 91450AZ0180113 Health Insurance Plan, 91450AZ0180113
-
Does Elite Gold + Vision + Adult Dental Health Insurance Plan, 91450AZ0180113 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (91450AZ0180113) Health Insurance Plan, Variant (91450AZ0180113-01) offer Disease Management Programs?
Does (91450AZ0180113) Health Insurance Plan, Variant (91450AZ0180113-01) have Out Of Country Coverage?
Does (91450AZ0180113) Health Insurance Plan, Variant (91450AZ0180113-01) have Out of Service Area Coverage?
Does (91450AZ0180113) Health Insurance Plan, Variant (91450AZ0180113-01) offer Disease Management Programs?
Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (91450AZ0180113-01) offer Disease Management Programs for Asthma?
Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (91450AZ0180113-01) offer Disease Management Programs for Heart disease?
Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (91450AZ0180113-01) offer Disease Management Programs for Diabetes?
Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (91450AZ0180113-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 16 Sep 2025 15:17 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