Standard Gold 1500 - 14624MS0010007 Health Insurance Plan
Primewell Health Services of Mississippi, Inc. health insurance plan with the Plan ID 14624MS0010007. The plan is called Standard Gold 1500.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 | 14624MS0010007 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Mississippi | ||||||||||||||||||
| Health Insurance Issuer | Primewell Health Services of Mississippi, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 14624MS0010007-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 04 Nov 2025 05:30 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 14624MS0010007-00 Standard On Exchange Plan - 14624MS0010007-01 |
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| Last Plan Update Date | Sat, 11 Jan 2025 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 04 Nov 2025 05:30 GMT |
Benefits of Standard Gold 1500 Health Insurance Plan, 14624MS0010007-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care. |
YES | No Charge |
No Charge |
| Basic Dental Care - Child
Exclusions: nan nan |
YES | 50.00% |
50.00% |
| Chemotherapy
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Exclusions: nan Must be medically necessary. A treatment plan outlining goals of therapy, mode of therapy and duration of therapy must be submitted to Company by the provider prior to the initiation of treatment. The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan Minimum stay of 48 hours; no charge for professional services |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year Exclusions: nan nan |
YES | No Charge |
No Charge |
| Diabetes Education
Exclusions: nan nan |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Dialysis
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Exclusions: nan Various limitations apply |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
Exclusions: nan The ER Copay is waived if the visit results in an inpatient admission. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan Air ambulance services are covered in only specified situations. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Exclusions: nan nan |
YES | 50.00% |
50.00% Coinsurance after deductible |
| Gender Affirming Care
Exclusions: nan nan |
NO | ||
| Generic Drugs
Exclusions: nan Quantity limits, authorizations and step therapy limits may apply. |
YES | $15.00 |
100.00% |
| Habilitation Services
Exclusions: nan 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. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Hearing Aids
Exclusions: nan nan |
NO | ||
| Home Health Care Services
Exclusions: nan May be available through the Care Management Program when provided by a network provider and prior authorization is received. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Limit: 6.0 Months per Lifetime Exclusions: nan Subject to Care Management. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan Copays, if applicable, are per day for first three days only. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
Exclusions: nan Lab services in the Emergency Room are subject to the deductible, if applicable. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care. |
YES | No Charge |
No Charge |
| Major Dental Care - Child
Exclusions: nan nan |
YES | 50.00% |
50.00% |
| Mental/Behavioral Health Inpatient Services
Exclusions: nan Inpatient treatment for mental/behavioral health disorders must be Authorized |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan nan |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Exclusions: nan Quantity limits, authorizations and step therapy limits may apply. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year Exclusions: nan Coverage only for diabetes education. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan Medically Necessary orthodontia only. |
YES | 50.00% |
50.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan Quantitative limits depend on the type of visit. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 36.0 Visit(s) per Year Exclusions: nan Benefits available for outpatient cardiac rehabilitation. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Exclusions: nan Quantity limits, authorizations and step therapy limits may apply. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Exclusions: nan Covered services must be included in Grade A and B Recommendations of the USPSTF and include all other preventive health services required by PPACA. |
YES | 0.00% |
50.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan nan |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: nan Various limitations apply as stated in the Benchmark plan. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
Exclusions: nan Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Exclusions: nan Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan Not covered for learning disabilities and development problems. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Exclusions: nan Covers exam and cleaning |
YES | No Charge |
No Charge |
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year Exclusions: nan An added benefit |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Exclusions: nan nan |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Routine Foot Care
Limit: 1.0 Visit(s) per Year Exclusions: nan Requires a Diabetes diagnosis. |
YES | 0.00% |
50.00% |
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period Exclusions: nan Three-day prior inpatient stay |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
Exclusions: nan nan |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Exclusions: nan Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan Inpatient treatment for substance abuse must be Authorized |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan nan |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Transplant
Exclusions: nan Non-EHB and out-of-network transplant services not covered |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan Medical necessity documentation and a treatment plan must be submitted to and approved by the Company prior to the commencement of treatment. Prior authorization is required. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $45.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
Exclusions: Non-Vantage Weight Loss programs are excluded. Vantage Weight Loss programs are covered as part of the Vantage Wellness Program. |
YES | 0.00% |
50.00% |
| Well Baby Visits and Care
Exclusions: nan nan |
YES | 0.00% |
50.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Standard Gold 1500 Health Insurance Plan Variant 14624MS0010007-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780612576352931 |
| 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 | Design 1 |
| Disease Management Programs Offered | Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Weight Loss Programs |
| EHB Percent of Total Premium | 0.97776179 |
| First Tier Utilization | 100% |
| Formulary ID | MSF006 |
| Formulary URL | URL |
| HIOS Product ID | 14624MS001 |
| Import Date | 2025-01-11 00:01:52 |
| 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 ID | 14624 |
| Issuer Marketplace Marketing Name | Primewell Health Services of Mississippi |
| 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 | MSN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Limited to Emergency Services only. Covered as in-network. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out-of-Network Deductible and Co-insurance |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 14624MS0010007-01 |
| Plan Marketing Name | Standard Gold 1500 |
| Plan Type | POS |
| Plan Variant Marketing Name | Standard Gold 1500 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,100 |
| SBC Scenario, Having a Baby, Copayment | $40 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MSS001 |
| Source Name | HIOS |
| Plan ID | 14624MS0010007 |
| State Code | MS |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $15000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $5000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $5,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Standard Gold 1500 Health Insurance Plan, 14624MS0010007
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Standard Gold 1500, 14624MS0010007 Health Insurance Plan, 14624MS0010007
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Does Standard Gold 1500 Health Insurance Plan, 14624MS0010007 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (14624MS0010007) Health Insurance Plan, Variant (14624MS0010007-01) offer Disease Management Programs?
Does (14624MS0010007) Health Insurance Plan, Variant (14624MS0010007-01) have Out Of Country Coverage?
Does (14624MS0010007) Health Insurance Plan, Variant (14624MS0010007-01) have Out of Service Area Coverage?
Does (14624MS0010007) Health Insurance Plan, Variant (14624MS0010007-01) offer Disease Management Programs?
Does Standard Gold 1500 Health Insurance Plan, Variant (14624MS0010007-01) offer Disease Management Programs for Heart disease?
Does Standard Gold 1500 Health Insurance Plan, Variant (14624MS0010007-01) offer Disease Management Programs for Depression?
Does Standard Gold 1500 Health Insurance Plan, Variant (14624MS0010007-01) offer Disease Management Programs for Diabetes?
Does Standard Gold 1500 Health Insurance Plan, Variant (14624MS0010007-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Standard Gold 1500 Health Insurance Plan, Variant (14624MS0010007-01) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 04 Nov 2025 05:30 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