Managed DentalGuard IL30 Family Plan - 87304IL0050006 Health Insurance Plan

First Commonwealth Insurance Company health insurance plan with the Plan ID 87304IL0050006. The plan is called Managed DentalGuard IL30 Family Plan.

Health Insurance Plan ID 87304IL0050006
Health Insurance Plan Year 2024
State Illinois
Health Insurance Issuer First Commonwealth Insurance Company
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 87304IL0050006-00
Provider Network(s) ['ILN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT).

Providers Illinois 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 - 87304IL0050006-00

Last Plan Update Date Tue, 15 Aug 2023 00:00 GMT
Last Import Date Tue, 30 Apr 2024 06:06 GMT

Benefits of Managed DentalGuard IL30 Family Plan Health Insurance Plan, 87304IL0050006-00

Benefit Covered In Network Out Of Network
Accidental Dental
NO
Basic Dental Care - Adult

Patient charge listed is a sample copayment of basic service D2140 (amalgam - one surface, primary or permanent). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure. Plan documents are the final arbiter of coverage.

YES

$0.00

100.00%
Basic Dental Care - Child

Patient charge listed is a sample copayment of basic service D2140 (amalgam - one surface, primary or permanent). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure but member responsibility for Pediatric Essential Benefits will not exceed the Maximum Out Of Pocket of $400 per child. Plan documents are the final arbiter of coverage.

YES

$0.00

100.00%
Dental Check-Up for Children

Patient charge listed is a sample copayment of preventive service D0120 (Periodontic oral evalution - established patient). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure but member responsibility for Pediatric Essential Benefits will not exceed the Maximum Out Of Pocket of $400 per child. Plan documents are the final arbiter of coverage.

YES

$0.00

100.00%
Major Dental Care - Adult

Patient charge listed is a sample copayment of major service D2510 (Inlay - metallic - one surface). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure. Plan documents are the final arbiter of coverage.

YES

$265.00

100.00%
Major Dental Care - Child

Limitations vary based on procedures.

YES

$265.00

100.00%
Orthodontia - Adult

Patient charge listed is a sample copayment of orthodontic service D8090 (Comprehensive orthodontic treatment of the adult dentition). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure. Plan documents are the final arbiter of coverage.

YES

$2,800.00

100.00%
Orthodontia - Child

Limitations vary based on procedures.

YES

$400.00

100.00%
Routine Dental Services (Adult)

Patient charge listed is a sample copayment of preventive service D0120 (Periodontic oral evalution - established patient). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure. Plan documents are the final arbiter of coverage.

YES

$0.00

100.00%

Managed DentalGuard IL30 Family Plan Health Insurance Plan Variant 87304IL0050006-00 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 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard High Off Exchange Plan
Dental Only Plan Yes
First Tier Utilization 100%
HIOS Product ID 87304IL005
Import Date 2023-08-15 20:02:25
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 87304
Issuer Marketplace Marketing Name First Commonwealth Insurance Company
Market Coverage SHOP (Small Group)
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Not Applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Group per group not applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Person per person not applicable
Medical EHB Deductible, In Network (Tier 1), Individual Not Applicable
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group $800 per group
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person $400 per person
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual $400
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual Not Applicable
Metal Level High
Multiple In Network Tiers No
National Network No
Network ID ILN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan Expiration Date 2024-12-31
Plan ID (Standard Component ID with Variant) 87304IL0050006-00
Plan Marketing Name Managed DentalGuard IL30 Family Plan
Plan Type HMO
Plan Variant Marketing Name Managed DentalGuard IL30 Family Plan
QHP/Non QHP Off the Exchange
Service Area ID ILS002
Source Name SERFF
Plan ID 87304IL0050006
State Code IL
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL

Copay & Coinsurance of Managed DentalGuard IL30 Family Plan Health Insurance Plan, 87304IL0050006

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

Frequently Asked Questions(FAQ) about Managed DentalGuard IL30 Family Plan, 87304IL0050006 Health Insurance Plan, 87304IL0050006

  • Does Managed DentalGuard IL30 Family Plan Health Insurance Plan, 87304IL0050006 support Mail Ordering?

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

  • Does (87304IL0050006) Health Insurance Plan, Variant (87304IL0050006-00) have Out Of Country Coverage?

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

    Does (87304IL0050006) Health Insurance Plan, Variant (87304IL0050006-00) 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, 30 Apr 2024 06:06 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