Wisconsin health plan · 2025

Premier $3,500 - 30% · 38166WI0310002

Security Health Plan of Wisconsin, Inc. offers this marketplace health insurance plan (Plan ID 38166WI0310002) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Gold Plan type: HMO CSR: Limited Cost Sharing Plan Variation Issuer: Security Health Plan of Wisconsin, Inc.
Telehealth Data pending HSA eligible No Dental Not listed Vision Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 78.34% (21.66% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$451 – $1996

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$6,500

$13000 per group

Review MOOP rules

Office visits

Primary care $25.00
Specialist $75.00
HSA Not eligible

Drug tiers

Generic $5.00
Preferred brand $50.00

View formulary tiers

$674 / mo before subsidies

≈ $8092 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1998 / mo before subsidies

≈ $23978 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$2638 / mo before subsidies

≈ $31656 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1508 / mo before subsidies

≈ $18100 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

No Charge, No Charge

Emergency Room Services

No Charge after deductible, 30.00% Coinsurance after deductible

Durable Medical Equipment

No Charge after deductible, 30.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Wisconsin). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Limited Cost Sharing Plan Variation plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

No Charge, No Charge

Emergency Room Services

No Charge after deductible, 30.00% Coinsurance after deductible

Durable Medical Equipment

No Charge after deductible, 30.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 38166WI0310002
Coverage year 2025
State Wisconsin
Issuer Security Health Plan of Wisconsin, Inc.
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 38166WI0310002-03
Available variants

Standard Off Exchange Plan · 38166WI0310002-00

Standard On Exchange Plan · 38166WI0310002-01

Open to Indians below 300% FPL · 38166WI0310002-02

Open to Indians above 300% FPL · 38166WI0310002-03
Last plan update Thu, 31 Oct 2024 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in Wisconsin N/A
PCPs in Wisconsin N/A
Telehealth support Data pending
Nationwide providers N/A

Provider network(s)

Providers Wisconsin 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

Drug coverage overview

7,563 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
NON-PREFERRED-GENERIC-AND-NON-PREFERRED-BRAND 4,068
SPECIALTY-DRUGS 2,055
ZERO-COST-SHARE-PREVENTIVE-DRUGS 1,440
Prior authorization Drugs
Required 1,438
Not Required 6,125
Step therapy Drugs
Required 451
Not Required 7,112
Quantity limits Drugs
Has Limit 2,126
No Limit 5,437

Customer highlights

What stands out for members

  • Issuer: Security Health Plan of Wisconsin, Inc. · Plan ID 38166WI0310002 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, Pregnancy, Weight Loss Programs.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 38166WI0310002-03 (Open to Indians above 300% FPL) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Diabetes Care Management

Coverage details pending

nan

Exclusions: nan

Diabetes Education

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Home Health Care Services

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.

Exclusions: nan

Laboratory Outpatient and Professional Services

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

nan

Exclusions: nan

Preventive Care/Screening/Immunization

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

nan

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

Limit: 20.0 Visit(s) per Year

Rehabilitative services must be short term.

Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders.

Rehabilitative Speech Therapy

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

Limit: 20.0 Visit(s) per Year

Rehabilitative services must be short term.

Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders.

Specialist Visit

$75.00
Tier 1 in-network $75.00
Out-of-network 100.00%

nan

Exclusions: nan

Urgent Care Centers or Facilities

$75.00
Tier 1 in-network $75.00
Out-of-network $75.00

nan

Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.

X-rays and Diagnostic Imaging

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

Intravenous chemotherapy is covered.

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: Limitations include: prenatal cradle (maternity belt), home delivery and home visits, services performed by a licensed midwife or certified professional midwife, services to determine gender, abortion procedures to end a pregnancy except as specifically stated above.

Dialysis

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Durable Medical Equipment

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: Limitations include: routine maintenance and replacement of equipment because of abuse and neglect and urable medical equipment and medical supplies for your comfort, personal hygiene, convenience or athletics-related conditions including, but not limited to, air conditioners, air cleaners, humidifiers, physical fitness equipment, disposable supplies, self-help devices not medical in nature, duplicate pieces of equipment, deluxe/nonstandard equipment and back-up equipment.

Emergency Room Services

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network No Charge after deductible, 30.00% Coinsurance after deductible

nan

Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.

Emergency Transportation/Ambulance

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network No Charge after deductible, 30.00% Coinsurance after deductible

nan

Exclusions: Limitations include: Ambulance transport to a home or outpatient setting, medical van transportation, non-emergency licensed professional ambulance services (unless authorized by Security Health Plan), first responders and rescue services and transportation from an acute facility to a sub-acute setting.

Hospice Services

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: Limitations include: financial or legal counseling, including estate planning or drafting of a will, homemaker or caretaker services that are not solely related to the members care including, but not limited to, sitter or companion services for the member or the members family, transportation, house cleaning, or physical maintenance of the house and pastoral counseling or funeral arrangements.

Inpatient Hospital Services (e.g., Hospital Stay)

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Inpatient Physician and Surgical Services

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

nan

Exclusions: nan

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

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Outpatient Rehabilitation Services

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

Limit: 20.0 Visit(s) per Year

Rehabilitative services must be short term.

Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders.

Outpatient Surgery Physician/Surgical Services

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Radiation

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Skilled Nursing Facility

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 30.0 Days per Stay

nan

Exclusions: Limitations include: skilled nursing care and/or skilled therapy not prior approved by Security Health Plan and leave-of-absence days, respite care, custodial care, care exceeding the number of days shown in the members Schedule of Benefits.

Substance Abuse Disorder Inpatient Services

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

nan

Exclusions: nan

Transplant

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: Limitations include: lodging expenses including meals, expenses related to the recipients transportation except for medically necessary professionally licensed ambulance services, the purchase price of any bone marrow, organ or tissue that is sold rather than donated, services not ordered by a physician or surgeon, transplants involving non-human or artificial organs or

Mental health & substance use

Behavioral health visits and substance use treatment.

Autism Spectrum Disorders

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Mental Health Other

Coverage details pending

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 1.0 Item(s) per 3 Years

nan

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Routine Eye Exam for Children

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

Limit: 1.0 Visit(s) per Year

nan

Exclusions: nan

Well Baby Visits and Care

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$5.00
Tier 1 in-network $5.00
Out-of-network 100.00%

nan

Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

Non-Preferred Brand Drugs

$100.00
Tier 1 in-network $100.00
Out-of-network 100.00%

nan

Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

Preferred Brand Drugs

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

nan

Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

Prescription Drugs Other

Coverage details pending

nan

Exclusions: nan

Specialty Drugs

40.00%
Tier 1 in-network 40.00%
Out-of-network 100.00%

nan

Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Anesthesia

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

nan

Exclusions: nan

Infusion Therapy

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: Covered only when both of the following are true: nutritional education is required for a disease in which patient self-management is an important component of the treatment and there exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

nan

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

Coverage details pending

nan

Exclusions: nan

Bariatric Surgery

Coverage details pending

nan

Exclusions: nan

Cardiac Rehabilitation

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 36.0 Visit(s) per Year

nan

Exclusions: nan

Clinical Trials

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Cosmetic Surgery

Coverage details pending

nan

Exclusions: nan

Eye Glasses for Children

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 1.0 Item(s) per Year

nan

Exclusions: Limited to a selection of glasses approved by Security Health Plan

Gender Affirming Care

Coverage details pending

nan

Exclusions: Services covered only Hormone Therapy and Gender affirming services surgery

Habilitation Services

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

Limit: 20.0 Visit(s) per Year

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.

Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders.

Imaging (CT/PET Scans, MRIs)

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Infertility Treatment

Coverage details pending

nan

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Newborn Services Other

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

Coverage details pending

nan

Exclusions: nan

Reconstructive Surgery

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Routine Eye Exam (Adult)

Coverage details pending

nan

Exclusions: nan

Routine Foot Care

Coverage details pending

nan

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

No Charge after deductible, 30.00% Coinsurance after deductible
Tier 1 in-network No Charge after deductible, 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 4.0 Visit(s) per Year

nan

Exclusions: Limitations include: cosmetic or elective orthodontic care, periodontal care, general dental care, upper and lower jawbone surgery except as required for direct treatment of acute traumatic injury, dislocation, cancer or temporomandibular joint disorder and orthognathic surgery jaw alignment, except as a treatment of obstructive sleep apnea.

Variant attributes

Premier $3,500 - 30% · Variant 38166WI0310002-03

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Limited Cost Sharing Plan Variation

HIOS Product ID

38166WI031

Metal Level

Gold

Plan ID (Standard Component ID with Variant)

38166WI0310002-03

Plan Marketing Name

Premier $3,500 - 30%

Plan Variant Marketing Name

Premier $3,500 - 30%

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

38166

Issuer Marketplace Marketing Name

Security Health Plan

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

WIN003

Out of Country Coverage

Yes

Out of Country Coverage Description

Urgent and Emergent Care only

Out of Service Area Coverage

Yes

Out of Service Area Coverage Description

Urgent and Emergent Care only

Service Area ID

WIS003

State Code

WI

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.783354891424738

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

30.00%

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

No

Medical Drug Maximum Out of Pocket Integrated

Yes

Medical EHB Deductible, In Network (Tier 1), Default Coinsurance

30.00%

SBC Scenario, Having a Baby, Coinsurance

$2,700

SBC Scenario, Having a Baby, Copayment

$30

SBC Scenario, Having a Baby, Deductible

$3,500

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$1,500

SBC Scenario, Having Diabetes, Deductible

$500

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$80

SBC Scenario, Treatment of a Simple Fracture, Deductible

$2,600

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group

$13000 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person

$6500 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual

$6,500

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$13000 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$6500 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$6,500

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

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

WIF034

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$0

SBC Scenario, Having Diabetes, Limit

$0

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

1

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Drug EHB Deductible, Combined In/Out of Network, Family Per Group

$0 per group

Drug EHB Deductible, Combined In/Out of Network, Family Per Person

$0 per person

Drug EHB Deductible, Combined In/Out of Network, Individual

$0

Drug EHB Deductible, In Network (Tier 1), Family Per Group

$0 per group

Drug EHB Deductible, In Network (Tier 1), Family Per Person

$0 per person

Drug EHB Deductible, In Network (Tier 1), Individual

$0

Drug EHB Deductible, Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Out of Network, Individual

Not Applicable

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, Pregnancy, Weight Loss Programs

EHB Percent of Total Premium

1.0

First Tier Utilization

100%

Import Date

2024-10-31 01:01:26

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

Yes

Is a Referral Required for Specialist?

No

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

$7000 per group

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

$3500 per person

Medical EHB Deductible, Combined In/Out of Network, Individual

$3,500

Medical EHB Deductible, In Network (Tier 1), Family Per Group

$7000 per group

Medical EHB Deductible, In Network (Tier 1), Family Per Person

$3500 per person

Medical EHB Deductible, In Network (Tier 1), Individual

$3,500

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

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

HMO

QHP/Non QHP

Both

Source Name

HIOS

Plan ID

38166WI0310002

Unique Plan Design

No

Wellness Program Offered

Yes

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Wisconsin?

Premier $3,500 - 30% (38166WI0310002) is a Gold HMO from Security Health Plan of Wisconsin, Inc. in Wisconsin for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Premier $3,500 - 30% support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Premier $3,500 - 30% HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental coverage is not listed for this plan.

Vision add-ons: Child.

Does Premier $3,500 - 30% support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with Premier $3,500 - 30%?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, Pregnancy, Weight Loss Programs.

Is there out-of-country coverage for Premier $3,500 - 30%?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Urgent and Emergent Care only

Does Premier $3,500 - 30% cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Urgent and Emergent Care only

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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