Child-Only Offering
Allows Adult and Child-Only
Composite Rating Offered
No
Drug EHB Deductible, Combined In/Out of Network, Family
$4000 per person | $8000 per group
Drug EHB Deductible, Combined In/Out of Network, Individual
$4,000
Drug EHB Deductible, In Network (Tier 1), Family
$2000 per person | $4000 per group
Drug EHB Deductible, In Network (Tier 1), Individual
$2,000
Drug EHB Deductible, Out of Network, Family
$2000 per person | $4000 per group
Drug EHB Deductible, Out of Network, Individual
$2,000
Design Type
Not Applicable
Disease Management Programs Offered
Pregnancy, Pain Management, Depression, Low Back Pain, Heart Disease
EHB Percent of Total Premium
99%
First Tier Utilization
100%
Notice Required for Pregnancy
No
Is a Referral Required for Specialist?
Yes
Medical EHB Deductible, Combined In/Out of Network, Family
$21800 per person | $43600 per group
Medical EHB Deductible, Combined In/Out of Network, Individual
$21,800
Medical EHB Deductible, In Network (Tier 1), Family
$5500 per person | $11000 per group
Medical EHB Deductible, In Network (Tier 1), Individual
$5,500
Medical EHB Deductible, Out of Network, Family
$16300 per person | $32600 per group
Medical EHB Deductible, Out of Network, Individual
$16,300
Plan Effective Date
1/1/2025
Specialist Requiring a Referral
A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.
Wellness Program Offered
No