Tiered Choice Plus Silver I305 with Dental & Vision - 37833WI0380261 Health Insurance Plan

Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 37833WI0380261. The plan is called Tiered Choice Plus Silver I305 with Dental & Vision.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.67% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.33% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.03% (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 28.97% 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 37833WI0380261
Health Insurance Plan Year 2023
State Wisconsin
Health Insurance Issuer Quartz Health Benefit Plans Corporation
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 37833WI0380261-03
Provider Network(s) ['WIN003']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 02 Jul 2024 06:38 GMT).

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
Available Variants of the Health Plan

Standard Off Exchange Plan - 37833WI0380261-00

Standard On Exchange Plan - 37833WI0380261-01

Open to Indians below 300% FPL - 37833WI0380261-02

Open to Indians above 300% FPL - 37833WI0380261-03

73% AV Silver Plan - 37833WI0380261-04

87% AV Silver Plan - 37833WI0380261-05

94% AV Silver Plan - 37833WI0380261-06

Last Plan Update Date Fri, 28 Apr 2023 00:00 GMT
Last Import Date Tue, 02 Jul 2024 06:38 GMT

Benefits of Tiered Choice Plus Silver I305 with Dental & Vision Health Insurance Plan, 37833WI0380261-03

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Acupuncture

Limit: 12.0 Visit(s) per Year

Acupuncture services are covered only when ? ? Provided for the treatment of nausea / vomiting when associated with pregnancy, chemotherapy, or for the treatment of chronic pain, including migraine or tension headaches, fibromyalgia, chronic neck and back pain, knee pain due to arthritis, or myofascial pain. Acupuncture is not covered for the treatment of any other conditions; ? Obtained from licensed acupuncture Providers or licensed physicians.

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Allergy Testing
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult

Limit: 1000.0 Dollars per Benefit Period

Basic and major dental can't exceed $1000

YES

20.00%

100.00%
Basic Dental Care - Child
YES

30.00%

100.00%
Chemotherapy

Intravenous chemotherapy is covered.

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Chiropractic Care

Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.

YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Clinical Trials
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Copay per Day

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Dental Anesthesia
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Diabetes Care Management
YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Diabetes Education
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Dialysis
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

Tier 1: $1,000.00

Tier 2: $1,000.00

$1,000.00
Emergency Transportation/Ambulance
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

Tier 1: $35.00

Tier 2: $35.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Benefit Period

limited to 20 visits per therapy discipline. 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

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Hearing Aids

1 item per ear every 36 Months

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Benefit Period

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

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Hospice Services
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult

Limit: 1000.0 Dollars per Benefit Period

Basic and major dental can't exceed $1000

YES

50.00%

100.00%
Major Dental Care - Child

When medically necessary.

YES

50.00%

100.00%
Mental/Behavioral Health Inpatient Services
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Non-Preferred Brand Drugs
YES

Tier 1: 50.00%

Tier 2: 50.00%

100.00%
Nutritional Counseling
YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

When medically necessary.

YES

50.00%

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Limited to 20 visits per therapy discipline. Rehabilitative services must be short term.

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

Tier 1: $150.00

Tier 2: $150.00

100.00%
Prenatal and Postnatal Care
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Radiation
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Benefit Period

20 OT visits and 20 PT visits.

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Rehabilitative services must be short term.

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

100.00%
Routine Eye Exam (Adult)
YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Routine Eye Exam for Children
YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Routine Foot Care

Covered from PCP for all members, at specialist only for diabetic members

YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Skilled Nursing Facility

Limit: 30.0 Days per Stay

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

Tier 1: $100.00

Tier 2: $200.00

100.00%
Specialty Drugs
YES

Tier 1: 60.00%

Tier 2: 60.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

Tier 1: $50.00

Tier 2: $100.00

100.00%
Transplant
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

Tier 1: $100.00

Tier 2: $100.00

$100.00
Virtual Visit
YES

Tier 1: $0.00

Tier 2: $100.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging
YES

Tier 1: $100.00

Tier 2: $200.00

100.00%

TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan Variant 37833WI0380261-03 Attributes

Plan Attribute Value
AV Calculator Output Number 0.710345623
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Limited Cost Sharing Plan Variation
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
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, In Network (Tier 2), Default Coinsurance 0.00%
Drug EHB Deductible, In Network (Tier 2), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 2), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 2), 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, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 0.9557
First Tier Utilization 80%
Formulary ID WIF001
Formulary URL URL
HIOS Product ID 37833WI038
Import Date 4/28/2023 4:01
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 Actuarial Value 71.67%
Issuer ID 37833
Issuer Marketplace Marketing Name Quartz
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
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), Default Coinsurance 40.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $8000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $4000 per person
Medical EHB Deductible, In Network (Tier 1), Individual $4,000
Medical EHB Deductible, In Network (Tier 2), Default Coinsurance 40.00%
Medical EHB Deductible, In Network (Tier 2), Family Per Group $16000 per group
Medical EHB Deductible, In Network (Tier 2), Family Per Person $8000 per person
Medical EHB Deductible, In Network (Tier 2), Individual $8,000
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
Metal Level Silver
Multiple In Network Tiers Yes
National Network No
Network ID WIN003
Out of Country Coverage No
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 37833WI0380261-03
Plan Marketing Name Tiered Choice Plus Silver I305 with Dental & Vision
Plan Type HMO
Plan Variant Marketing Name TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,800
SBC Scenario, Having a Baby, Copayment $400
SBC Scenario, Having a Baby, Deductible $4,000
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,100
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $1,000
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,600
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 20%
Service Area ID WIS003
Source Name HIOS
Plan ID 37833WI0380261
State Code WI
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $16000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $9,100
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Tiered Choice Plus Silver I305 with Dental & Vision Health Insurance Plan, 37833WI0380261

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

Frequently Asked Questions(FAQ) about Tiered Choice Plus Silver I305 with Dental & Vision, 37833WI0380261 Health Insurance Plan, 37833WI0380261

  • Does Tiered Choice Plus Silver I305 with Dental & Vision Health Insurance Plan, 37833WI0380261 support Mail Ordering?

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

  • Does (37833WI0380261) Health Insurance Plan, Variant (37833WI0380261-03) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (37833WI0380261) Health Insurance Plan, Variant (37833WI0380261-03) have Out Of Country Coverage?

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

    Does (37833WI0380261) Health Insurance Plan, Variant (37833WI0380261-03) have Out of Service Area Coverage?

    Yes. Details: Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization

    Does (37833WI0380261) Health Insurance Plan, Variant (37833WI0380261-03) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan, Variant (37833WI0380261-03) offer Disease Management Programs for Asthma?

    Yes, the TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan Variant 37833WI0380261-03 offers Disease Management Program for Asthma.

    Does TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan, Variant (37833WI0380261-03) offer Disease Management Programs for Heart disease?

    Yes, the TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan Variant 37833WI0380261-03 offers Disease Management Program for Heart disease.

    Does TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan, Variant (37833WI0380261-03) offer Disease Management Programs for Depression?

    Yes, the TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan Variant 37833WI0380261-03 offers Disease Management Program for Depression.

    Does TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan, Variant (37833WI0380261-03) offer Disease Management Programs for Diabetes?

    Yes, the TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan Variant 37833WI0380261-03 offers Disease Management Program for Diabetes.

    Does TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan, Variant (37833WI0380261-03) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan Variant 37833WI0380261-03 offers Disease Management Program for High blood pressure & high cholesterol.

    Does TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan, Variant (37833WI0380261-03) offer Disease Management Programs for Pregnancy?

    Yes, the TIERED CHOICE PLUS SILVER I305-03 LIMITED COST SHARE VALUE TIER RX W/DENTAL & VISION Health Insurance Plan Variant 37833WI0380261-03 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 02 Jul 2024 06:38 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