Healthy Premier Silver Standard - 42261UT0060020 Health Insurance Plan

University of Utah Health Insurance Plans health insurance plan with the Plan ID 42261UT0060020. The plan is called Healthy Premier Silver Standard.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 42261UT0060020
Health Insurance Plan Year 2024
State Utah
Health Insurance Issuer University of Utah Health Insurance Plans
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 42261UT0060020-02
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT).

Providers Utah 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 Off Exchange Plan - 42261UT0060020-00

Standard On Exchange Plan - 42261UT0060020-01

Open to Indians below 300% FPL - 42261UT0060020-02

Open to Indians above 300% FPL - 42261UT0060020-03

73% AV Silver Plan - 42261UT0060020-04

87% AV Silver Plan - 42261UT0060020-05

94% AV Silver Plan - 42261UT0060020-06

Last Plan Update Date Mon, 18 Dec 2023 00:00 GMT
Last Import Date Tue, 22 Oct 2024 06:47 GMT

Benefits of Healthy Premier Silver Standard Health Insurance Plan, 42261UT0060020-02

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

Charges for office visits in connection with repetitive injections are not covered. Sublingual or colorimetric allergy testing.

YES

$0.00, 0.00%

100.00%
Autism Spectrum Disorders
YES

$0.00, 0.00%

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Must be for the diagnosis of diabetes.

YES

$0.00, 0.00%

100.00%
Dialysis
YES

$0.00, 0.00%

100.00%
Durable Medical Equipment

DME over $1000, rentals, that exceed 60 days, or as indicated in Appendix A of the Master Policy require Pre-authorization.

YES

$0.00, 0.00%

100.00%
Emergency Room Services
YES

$0.00, 0.00%

$0.00, 0.00%
Emergency Transportation/Ambulance
YES

$0.00, 0.00%

$0.00, 0.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Lenses only.

YES

$0.00, 0.00%

$0.00, 0.00%
Gender Affirming Care
NO
Generic Drugs

Limit: 30.0 Item(s) per Month

YES

$0.00, 0.00%

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Benefit Period

Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year

YES

$0.00, 0.00%

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 30.0 Visit(s) per Benefit Period

YES

$0.00, 0.00%

100.00%
Hospice Services

Limit: 6.0 Months per 3 Years

Requires Pre-authorization and Medical Case Management.

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$0.00, 0.00%

100.00%
Inherited Metabolic Disorder - PKU
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

100.00%
Laboratory Outpatient and Professional Services
YES

$0.00, 0.00%

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Requires Pre-authorization.

YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Outpatient Services

Office Visits will be subject to a Copay, All other outpatient services are subject to the deductible and coinsurance

YES

$0.00, 0.00%

100.00%
Non-Preferred Brand Drugs

Limit: 30.0 Item(s) per Month

YES

$0.00, 0.00%

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Benefit Period

Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year

YES

$0.00, 0.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

100.00%
Preferred Brand Drugs

Limit: 30.0 Item(s) per Month

YES

$0.00, 0.00%

100.00%
Prenatal and Postnatal Care
YES

$0.00, 0.00%

100.00%
Preventive Care/Screening/Immunization
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
NO
Radiation
YES

$0.00, 0.00%

100.00%
Reconstructive Surgery

Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy.

YES

$0.00, 0.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Benefit Period

Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year

YES

$0.00, 0.00%

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year

YES

$0.00, 0.00%

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

Limit: 1.0 Visit(s) per Benefit Period

YES

$0.00, 0.00%

$0.00, 0.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Visit(s) per Benefit Period

Requires Pre-authorization and Medical Case Management.

YES

$0.00, 0.00%

100.00%
Specialist Visit
YES

$0.00, 0.00%

100.00%
Specialty Drugs

Limit: 30.0 Item(s) per Month

YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Inpatient Services

Requires Pre-authorization.

YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Outpatient Services

Office Visits will be subject to a Copay, All other outpatient services are subject to the deductible and coinsurance

YES

$0.00, 0.00%

100.00%
Transplant
YES

$0.00, 0.00%

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$0.00, 0.00%

0.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Benefit should mirror preventive care/screening/immunization.

YES

$0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$0.00, 0.00%

100.00%

Healthy Premier Silver Standard Health Insurance Plan Variant 42261UT0060020-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1.0
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Zero Cost Sharing Plan Variation
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID UTF004
Formulary URL URL
HIOS Product ID 42261UT006
Import Date 2023-12-18 20:02:01
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 42261
Issuer Marketplace Marketing Name University of Utah Health Plans
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID UTN001
Out of Country Coverage No
Out of Country Coverage Description Emergent Only
Out of Service Area Coverage No
Out of Service Area Coverage Description Emergent Only
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan Expiration Date 2024-12-31
Plan ID (Standard Component ID with Variant) 42261UT0060020-02
Plan Level Exclusions See Plan Document
Plan Marketing Name Healthy Premier Silver Standard
Plan Type EPO
Plan Variant Marketing Name Healthy Premier Silver 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 $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
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 $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID UTS002
Source Name SERFF
Plan ID 42261UT0060020
State Code UT
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
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 $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 $0 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Healthy Premier Silver Standard Health Insurance Plan, 42261UT0060020

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

Frequently Asked Questions(FAQ) about Healthy Premier Silver Standard, 42261UT0060020 Health Insurance Plan, 42261UT0060020

  • Does Healthy Premier Silver Standard Health Insurance Plan, 42261UT0060020 support Mail Ordering?

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

  • Does (42261UT0060020) Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (42261UT0060020) Health Insurance Plan, Variant (42261UT0060020-02) have Out Of Country Coverage?

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

    Does (42261UT0060020) Health Insurance Plan, Variant (42261UT0060020-02) have Out of Service Area Coverage?

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

    Does (42261UT0060020) Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Healthy Premier Silver Standard Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs for Asthma?

    Yes, the Healthy Premier Silver Standard Health Insurance Plan Variant 42261UT0060020-02 offers Disease Management Program for Asthma.

    Does Healthy Premier Silver Standard Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs for Heart disease?

    Yes, the Healthy Premier Silver Standard Health Insurance Plan Variant 42261UT0060020-02 offers Disease Management Program for Heart disease.

    Does Healthy Premier Silver Standard Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs for Depression?

    Yes, the Healthy Premier Silver Standard Health Insurance Plan Variant 42261UT0060020-02 offers Disease Management Program for Depression.

    Does Healthy Premier Silver Standard Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs for Diabetes?

    Yes, the Healthy Premier Silver Standard Health Insurance Plan Variant 42261UT0060020-02 offers Disease Management Program for Diabetes.

    Does Healthy Premier Silver Standard Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Healthy Premier Silver Standard Health Insurance Plan Variant 42261UT0060020-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Healthy Premier Silver Standard Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs for Low back pain?

    Yes, the Healthy Premier Silver Standard Health Insurance Plan Variant 42261UT0060020-02 offers Disease Management Program for Low back pain.

    Does Healthy Premier Silver Standard Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs for Pregnancy?

    Yes, the Healthy Premier Silver Standard Health Insurance Plan Variant 42261UT0060020-02 offers Disease Management Program for Pregnancy.

    Does Healthy Premier Silver Standard Health Insurance Plan, Variant (42261UT0060020-02) offer Disease Management Programs for Weight loss programs?

    Yes, the Healthy Premier Silver Standard Health Insurance Plan Variant 42261UT0060020-02 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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