SummaCare Value with 3 Free PCP Visits + Adult Vision - 52664OH1540001 Health Insurance Plan
Summa Insurance Company, Inc. health insurance plan with the Plan ID 52664OH1540001. The plan is called SummaCare Value with 3 Free PCP Visits + Adult Vision.
| Health Insurance Plan ID | 52664OH1540001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Ohio | ||||||||||||||||||
| Health Insurance Issuer | Summa Insurance Company, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 52664OH1540001-00 | ||||||||||||||||||
| Provider Network(s) | SCCONNECT | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Jun 2025 12:51 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 17 Jun 2025 12:51 GMT |
SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan Variant 52664OH1540001-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| 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 Catastrophic Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.99 |
| First Tier Utilization | 100% |
| Formulary ID | OHF001 |
| Formulary URL | URL |
| HIOS Product ID | 52664OH154 |
| Import Date | 2024-08-14 20:01:41 |
| 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 | 52664 |
| Issuer Marketplace Marketing Name | SummaCare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Catastrophic |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | OHN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Coverage |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergent and Urgent Care Coverage |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 52664OH1540001-00 |
| Plan Marketing Name | SummaCare Value with 3 Free PCP Visits + Adult Vision |
| Plan Type | HMO |
| Plan Variant Marketing Name | SummaCare Value with 3 Free PCP Visits + Adult Vision |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $9,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $2,300 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OHS001 |
| Source Name | SERFF |
| Plan ID | 52664OH1540001 |
| State Code | OH |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $9,200 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $18400 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $9200 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $9,200 |
| 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 | $18400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,200 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| 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 SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan, 52664OH1540001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about SummaCare Value with 3 Free PCP Visits + Adult Vision, 52664OH1540001 Health Insurance Plan, 52664OH1540001
-
Does SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan, 52664OH1540001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (52664OH1540001) Health Insurance Plan, Variant (52664OH1540001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, Pain Management, Pregnancy, Weight Loss Programs
Does (52664OH1540001) Health Insurance Plan, Variant (52664OH1540001-00) have Out Of Country Coverage?
Yes. Details: Emergency Coverage
Does (52664OH1540001) Health Insurance Plan, Variant (52664OH1540001-00) have Out of Service Area Coverage?
Yes. Details: Emergent and Urgent Care Coverage
Does (52664OH1540001) Health Insurance Plan, Variant (52664OH1540001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, Pain Management, Pregnancy, Weight Loss Programs
Does SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan, Variant (52664OH1540001-00) offer Disease Management Programs for Asthma?
Yes, the SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan Variant
52664OH1540001-00 offers Disease
Management Program for Asthma.
Does SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan, Variant (52664OH1540001-00) offer Disease Management Programs for Heart disease?
Yes, the SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan Variant
52664OH1540001-00 offers Disease
Management Program for Heart disease.
Does SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan, Variant (52664OH1540001-00) offer Disease Management Programs for Depression?
Yes, the SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan Variant
52664OH1540001-00 offers Disease
Management Program for Depression.
Does SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan, Variant (52664OH1540001-00) offer Disease Management Programs for Diabetes?
Yes, the SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan Variant
52664OH1540001-00 offers Disease
Management Program for Diabetes.
Does SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan, Variant (52664OH1540001-00) offer Disease Management Programs for Pregnancy?
Yes, the SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan Variant
52664OH1540001-00 offers Disease
Management Program for Pregnancy.
Does SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan, Variant (52664OH1540001-00) offer Disease Management Programs for Weight loss programs?
Yes, the SummaCare Value with 3 Free PCP Visits + Adult Vision Health Insurance Plan Variant
52664OH1540001-00 offers Disease
Management Program for Weight loss programs.
Disclaimer: This is based on the import(Date: Tue, 17 Jun 2025 12:51 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