WellFirst by Medica Silver HSA-E HDHP 3550X - 65280IL0010008 Health Insurance Plan

SSM Health Plan health insurance plan with the Plan ID 65280IL0010008. The plan is called WellFirst by Medica Silver HSA-E HDHP 3550X.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.63% (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 29.37% 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 65280IL0010008
Health Insurance Plan Year 2024
State Illinois
Health Insurance Issuer SSM Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 65280IL0010008-00
Provider Network(s) WELLFIRSTBENEFITSIL
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Jul 2024 06:14 GMT).

Providers Illinois All US States
All 12331 69568
PCP 275 1095
Allergy N/A 11
OB/GYN 4 48
Dentists 1 5
Available Variants of the Health Plan

Standard Off Exchange Plan - 65280IL0010008-00

Standard On Exchange Plan - 65280IL0010008-01

Open to Indians below 300% FPL - 65280IL0010008-02

Open to Indians above 300% FPL - 65280IL0010008-03

73% AV Silver Plan - 65280IL0010008-04

87% AV Silver Plan - 65280IL0010008-05

94% AV Silver Plan - 65280IL0010008-06

Last Plan Update Date Tue, 24 Oct 2023 00:00 GMT
Last Import Date Tue, 16 Jul 2024 06:14 GMT

Benefits of WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan, 65280IL0010008-00

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

Exclusions: Surgery performed to correct functional deformities of the mandible or maxilla; correction of malocclusion; orthognathic surgery; orthodontic care, periodontic care or general dental care; restoration (crowns and root canals are covered only if such treatments are the only clinically acceptable treatments for the trauma/accidental injury); tooth damage due to eating, chewing or biting;

These benefits are intended for dental treatment needed to remove, repair, replace, restore and/or reposition sound, natural teeth damaged, lost, or removed due to an injury. The term "injured" does not include conditions resulting from eating, chewing or biting. To be eligible for coverage, the services must be medically necessary while you are enrolled under this policy. The tooth must meet the definition of "sound, natural tooth".

YES

20.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

20.00% Coinsurance after deductible

100.00%
Bariatric Surgery

Exclusions: Treatments, services or procedures that are not medically necessary nor approved by us; diet supplements; low-calorie foods and beverages; weight loss books and materials obtained through the program or other outside sources; body sculpting procedures related to weight loss.

YES

20.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

20.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 25.0 Visit(s) per Benefit Period

Exclusions: Maintenance or long-term therapy.

YES

20.00% Coinsurance after deductible

100.00%
Cosmetic Surgery

Exclusions: Cosmetic surgery performed solely for appearance improvement.

Coverage includes the functional repair or restoration of any body part when necessary to achieve normal body functioning.

YES

20.00% Coinsurance after deductible

100.00%
Delivery and All Inpatient Services for Maternity Care

Exclusions: Amniocentesis, CVS (Chorionic Villi Sampling), or non-invasive pre-natal testing when performed exclusively for sex determination; birthing classes; services, drugs or supplies related to abortions, except when a woman suffers from a physical disorder, physical injury, or physical illness that would place the woman in danger of death unless an abortion is performed; home or intentional out-of-hospital deliveries; maternity services received outside the service area during the last 30 days of the pregnancy, except for emergency or urgent care services; treatment, services or supplies for a non-member traditional surrogate or gestational carrier, who is not covered under this policy.

65280IL0010001-01 - [20.00% Coinsurance after deductible]; 65280IL0010001-02 - [0]; 65280IL0010001-03 - [20.00% Coinsurance after deductible]; 65280IL0010002-01 - [30.00% Coinsurance after deductible]; 65280IL0010002-02 - [0]; 65280IL0010002-03 - [30.00% Coinsurance after deductible]; 65280IL0010002-04 - [30.00% Coinsurance after deductible]; 65280IL0010002-05 - [10.00% Coinsurance after deductible]; 65280IL0010002-06 - [5.00% Coinsurance after deductible]; 65280IL0010003-01 - [No Charge after deductible]; 65280IL0010003-02 - [0]; 65280IL0010003-03 - [No Charge after deductible]; 65280IL0010005-01 - [No Charge after deductible]; 65280IL0010005-02 - [0]; 65280IL0010005-03 - [No Charge after deductible]; 65280IL0010006-01 - [30.00% Coinsurance after deductible]; 65280IL0010006-02 - [0]; 65280IL0010006-03 - [30.00% Coinsurance after deductible]; 65280IL0010006-04 - [20.00% Coinsurance after deductible]; 65280IL0010006-05 - [10.00% Coinsurance after deductible]; 65280IL0010006-06 - [5.00% Coinsurance after deductible]; 65280IL0010007-01 - [No Charge after deductible]; 65280IL0010007-02 - [0]; 65280IL0010007-03 - [No Charge after deductible]; 65280IL0010008-01 - [20.00% Coinsurance after deductible]; 65280IL0010008-02 - [0]; 65280IL0010008-03 - [20.00% Coinsurance after deductible]; 65280IL0010008-04 - [20.00% Coinsurance after deductible]; 65280IL0010008-05 - [5.00% Coinsurance after deductible]; 65280IL0010008-06 - [5.00% Coinsurance after deductible]; 65280IL0010009-01 - [No Charge after deductible]; 65280IL0010009-02 - [0]; 65280IL0010009-03 - [No Charge after deductible]; 65280IL0010010-01 - [No Charge after deductible]

YES

20.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Exclusions: Educational services, except for diabetic education.

Diabetic education; diabetic self-management training classes.

YES

20.00% Coinsurance after deductible

100.00%
Dialysis
YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Exclusions: Medical supplies and durable medical equipment for comfort, personal hygiene and convenience, regardless of medical necessity of such items; Enteral feedings, unless they are the sole source of nutrition (enteral feedings of standard infant formulas, standard baby food and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition); Home testing and monitoring supplies and related equipment, except as covered by our medical policy; Equipment, models or devices that have features over and above what is Medically Necessary (Coverage will be limited to the standard model as determined by us); Non-prescription elastic support or anti-embolism stockings; Shoes or foot orthotics not custom-made and purchased over the counter; Any durable medical equipment or supplies used for work, athletic, or job enhancement purposes; Back-up equipment (a second piece); Replacement of durable medical equipment more frequently than every three years, unless defined by our medical policy or mandated by law; Replacement of an item that is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect; Items that can be purchased over the counter, unless coverage is required by state or federal law; technology devices that are not primarily and customarily used to serve a medical purpose such as desktop computers, portable multi-media players, smart phones, tablet devices and similar items are not considered Durable Medical Equipment.

Covers medical supplies and durable medical equipment. Examples include, but are not limited to: wheelchairs, tube feeding nutrition supplies; hospital beds; oxygen and respiratory equipment; walking aids; orthopedic products; urological and ostomy supplies. Oral nutrition (We cover nutritional support that is taken orally (i.e., by mouth) when mandated by law and ordered by a health care provider. Examples include, but are not limited to, donor breast milk and infant formula.). Orthotics and prosthetics. Diabetic durable equipment and insulin infusion pumps (Insulin infusion pumps are limited to one pump per contract period and the member must use the pump for 30 days before purchasing). Other medical supplies as determined by us.

YES

20.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Exclusions: Non-emergency or non-urgent ground or air ambulance services or transportation, unless the transportation or service is listed as a covered expense or prior authorized by us; charges for, or in connection with, any other form of travel, unless otherwise stated in this section; member's condition does not meet medical criteria for ambulance services or transportation; any ambulance transportation or services initiated for convenience or non-medical reasons.

YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Exclusions: Blended lenses; replacement of lost, stolen or broken lenses or frames; two pair of glasses as a substitute for bifocals; any vision services, treatment or materials not specifically listed as covered.

One pair of prescription eyeglasses per year, as follows: glass or plastic lenses; single vision, lined bifocal and lined trifocal; polycarbonate lenses; frame; contact lenses. Benefits for contact lenses are in lieu of your eyeglass lens benefit. If you receive contact lenses, no benefit will be available for eyeglasses until the next contract period.

YES

20.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

20.00% Coinsurance after deductible

100.00%
Habilitation Services

Exclusions: Custodial care; daycare; recreational care; respite care; vocational or life training.

Habilitative Services and devices are those services and devices that help a person keep, learn, or improve skills and functioning for daily living. Covered expenses include medically necessary physical therapy, occupational therapy and speech therapy, counseling, behavioral health services, and services for developmental delay.

YES

20.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 2.0 Item(s) per 2 Years

Exclusions: Batteries and chargers for hearing aids. Hearing aids that are available over-the-counter.

Limited to one hearing aid per ear or one set of bilateral hearing aids (both ears) and ear molds, including dispensing fees (Benefits are available per Benefit Period. The Benefit Period is 24 consecutive months from the date the benefit is first used). Repairs as medically necessary. The hearing aid must be repaired by/purchased from an authorized provider. Cochlear implants, for children and adults, including procedures for implantation and post-cochlear implant aural therapy. Bone-anchored hearing aids.

YES

20.00% Coinsurance after deductible

100.00%
Home Health Care Services

Exclusions: Residential care; home care services provided by a family member or someone who resides with the member; custodial care or any service that is not required to be provided by a skilled/licensed provider.

YES

20.00% Coinsurance after deductible

100.00%
Hospice Services

Exclusions: Residential care; services provided by volunteers; housekeeping or homemaking services; respite care for more than five consecutive days.

YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Infertility Treatment

Exclusions: Expenses incurred for cryo preservation or storage of sperm, eggs, and embryos except for those procedures which use a cryo-preserved substance or as required by law; selected termination of an embryo, provided, however, termination will be covered where the mother's life would be in danger if all embryos were carried to full term; non-medical costs of an egg or sperm donor; travel costs for travel within 100 miles of the member's home or travel costs not medically necessary; infertility treatments which are deemed experimental or investigational, in writing, by the American Society for Reproductive Medicine or the American College of Obstetricians or Gynecologists; infertility treatment rendered to dependent member under age 18.

Limitations vary based on procedures.

YES

20.00% Coinsurance after deductible

100.00%
Infusion Therapy

Exclusions: A drug or biologic that is not considered medically necessary; home infusion administered by a family member or someone who resides with a family member.

YES

20.00% Coinsurance after deductible

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

Exclusions: Take home drugs and supplies dispensed by the hospital, unless a written prescription is obtained and filled at a network pharmacy; hospital stays that are extended for reasons other than medical necessity; a continued hospital stay, if the attending health care provider has documented that care could effectively be provided in a less acute care setting; separate charges for personal comfort or convenience items.

YES

20.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Benefit provided for outpatient services and when these services are related to surgery or medical care.

YES

20.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Exclusions: Biofeedback; family counseling for non-medical reasons; wilderness and camp programs, boarding school, academy-vocational programs and group homes; halfway houses; hypnotherapy; long-term or maintenance therapy; marriage counseling; phototherapy.

YES

20.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs
YES

20.00% Coinsurance after deductible

100.00%
Nutritional Counseling

A registered or certified dietitian must give or supervise these services.

YES

20.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Exclusions: Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease.

These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient's home or be a family member.

YES

20.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

20.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care

Exclusions: Amniocentesis, CVS (Chorionic Villi Sampling), or non-invasive pre-natal testing when performed exclusively for sex determination; birthing classes; services, drugs or supplies related to abortions, except when a woman suffers from a physical disorder, physical injury, or physical illness that would place the woman in danger of death unless an abortion is performed; home or intentional out-of-hospital deliveries; maternity services received outside the service area during the last 30 days of the pregnancy, except for emergency or urgent care services; treatment, services or supplies for a non-member traditional surrogate or gestational carrier, who is not covered under this policy.

YES

20.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES 100.00%
Primary Care Visit to Treat an Injury or Illness
YES

20.00% Coinsurance after deductible

100.00%
Private-Duty Nursing

Exclusions: Private duty nursing services provided by a family member or someone who resides with the member; custodial care or any service that is not required to be provided by a skilled/licensed provider.

YES

20.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Exclusions: Medical supplies and durable medical equipment for comfort, personal hygiene and convenience, regardless of medical necessity of such items; home testing and monitoring supplies and related equipment, except as covered by our medical policy; equipment, models or devices that have features over and above what is medically necessary (Coverage will be limited to the standard model as determined by us); non-prescription elastic support or anti-embolism stockings; shoes or foot orthotics not custom-made and purchased over the counter; any durable medical equipment or supplies used for work, athletic, or job enhancement purposes; back-up equipment (a second piece); replacement of durable medical equipment more frequently than every three years, unless defined by our medical policy or mandated by law; replacement of an item that is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect; items that can be purchased over the counter, unless coverage is required by state or federal law; technology devices that are not primarily and customarily used to serve a medical purpose such as desktop computers, portable multi-media players, smart phones, tablet devices and similar items are not considered Durable Medical Equipment.

YES

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Exclusions: Non-medically necessary plastic surgery (This limitation does not affect coverage provided for breast reconstruction in connection with a mastectomy). Cosmetic services and procedures, including cosmetic surgery.

Only includes benefits for mastectomy-related services.

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Exclusions: Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease.

Medically necessary services resulting from illness or injury; speech and hearing screening examinations to determine the need for correction; post-cochlear implant aural therapy. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient's home or be a family member.

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Exclusions: Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease.

Medically necessary services resulting from illness or injury; speech and hearing screening examinations to determine the need for correction; post-cochlear implant aural therapy. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient's home or be a family member.

YES

20.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

Exclusions: Refractive eye surgery and radial keratotomy; contacts lenses (except as a part of cataract surgery or therapeutic contact lenses as defined by us); refractive exams related to contact lenses; any fitting of contact lenses (except for fitting of therapeutic contact lenses as defined by us); refraction aids for low vision and instruction in their use; visual therapy.

YES

20.00% Coinsurance after deductible

100.00%
Routine Foot Care

Exclusions: Podiatry services or routine foot care, except for persons diagnosed with diabetes. These include, but are not limited to: 1) the examination, treatment, or removal of all or part of corns, calluses, hypertrophy or hyperplasia of the skin or subcutaneous tissues of the feet; 2) the cutting, trimming, or other non-operative partial removal of toenails; or 3) any treatment or services in connection with any of these.

Only covered for persons diagnosed with diabetes.

YES

20.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Exclusions: Respite and residential care; any nursing facility services other than skilled nursing services, including intermediate care facilities and community re-entry programs; custodial care; charges for injectable medications administered in a nursing home when we do not cover the nursing home stay; tracheostomy care (if not skilled care); parenteral feeding or tube feeding care.

YES

20.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

20.00% Coinsurance after deductible

100.00%
Specialty Drugs
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Exclusions: Biofeedback; family counseling for non-medical reasons; wilderness and camp programs, boarding school, academy-vocational programs and group homes; halfway houses; hypnotherapy; long-term or maintenance therapy; marriage counseling; phototherapy.

YES

20.00% Coinsurance after deductible

100.00%
Transplant

Exclusions: Health services for organ and tissue transplants unless specifically covered under the policy; organ procurement costs for a member who is donating an organ to another person; health services for transplants involving permanent mechanical or animal organs; transplant services that are not performed at an approved facility.

YES

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Diagnostic procedures including diagnostic casts, diagnostic study models and bite adjustments and medically necessary surgical or non-surgical treatment for the correction of temporomandibular joint disorders (TMJ), if the following apply: Services are provided under the accepted standards of the profession of the health care provider providing the service; the procedure or device is medically appropriate and appropriate for the diagnosis or treatment of this condition; the purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction. Orthognathic surgery only for the treatment of TMJ (prior authorization may be required).

YES

20.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES 100.00%
X-rays and Diagnostic Imaging

Benefit provided for outpatient services and when these services are related to surgery or medical care.

YES

20.00% Coinsurance after deductible

100.00%

WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan Variant 65280IL0010008-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7063291836261179
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9994
First Tier Utilization 100%
Formulary ID ILF007
Formulary URL URL
HIOS Product ID 65280IL001
Import Date 2023-10-24 20:01:56
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 65280
Issuer Marketplace Marketing Name Medica
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID ILN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Only
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan Expiration Date 2024-12-31
Plan ID (Standard Component ID with Variant) 65280IL0010008-00
Plan Level Exclusions See policy or plan document for additional excluded services.
Plan Marketing Name WellFirst by Medica Silver HSA-E HDHP 3550X
Plan Type HMO
Plan Variant Marketing Name WellFirst by Medica Silver HSA-E HDHP 3550X
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,800
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $3,550
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $400
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $3,550
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 ILS001
Source Name SERFF
Plan ID 65280IL0010008
State Code IL
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $7100 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $3550 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $3,550
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 $15000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,500
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
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan, 65280IL0010008

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

Frequently Asked Questions(FAQ) about WellFirst by Medica Silver HSA-E HDHP 3550X, 65280IL0010008 Health Insurance Plan, 65280IL0010008

  • Does WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan, 65280IL0010008 support Mail Ordering?

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

  • Does (65280IL0010008) Health Insurance Plan, Variant (65280IL0010008-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (65280IL0010008) Health Insurance Plan, Variant (65280IL0010008-00) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (65280IL0010008) Health Insurance Plan, Variant (65280IL0010008-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

    Does (65280IL0010008) Health Insurance Plan, Variant (65280IL0010008-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan, Variant (65280IL0010008-00) offer Disease Management Programs for Asthma?

    Yes, the WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan Variant 65280IL0010008-00 offers Disease Management Program for Asthma.

    Does WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan, Variant (65280IL0010008-00) offer Disease Management Programs for Heart disease?

    Yes, the WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan Variant 65280IL0010008-00 offers Disease Management Program for Heart disease.

    Does WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan, Variant (65280IL0010008-00) offer Disease Management Programs for Diabetes?

    Yes, the WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan Variant 65280IL0010008-00 offers Disease Management Program for Diabetes.

    Does WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan, Variant (65280IL0010008-00) offer Disease Management Programs for Pregnancy?

    Yes, the WellFirst by Medica Silver HSA-E HDHP 3550X Health Insurance Plan Variant 65280IL0010008-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 16 Jul 2024 06:14 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