Begin Primary Care Cost-Sharing After Number Of Visits
0
Child-Only Offering
Allows Adult and Child-Only
Composite Rating Offered
No
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), Family Per Group
$9000 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person
$4500 per person
Drug EHB Deductible, In Network (Tier 1), Individual
$4,500
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
Design Type
Not Applicable
EHB Percent of Total Premium
0.96410006
First Tier Utilization
100%
Import Date
2024-08-16 01:01:20
Limited Cost Sharing Plan Variation - Estimated Advanced Payment
$0.00
Notice Required for Pregnancy
No
Is a Referral Required for Specialist?
No
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
$0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person
$0 per person
Medical EHB Deductible, In Network (Tier 1), Individual
$0
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 Level Exclusions
Some exclusions may apply. See the applicable Certificate of Coverage for details.
Wellness Program Offered
No