Medica Central Health Plan health insurance plan with the Plan ID 65280IL0010001. The plan is called WellFirst Gold Copay Plus 1500X (Free Virtual Visits & Transportation).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.97% (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 18.03% 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 | 65280IL0010001 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Illinois | ||||||||||||||||||
Health Insurance Issuer | Medica Central Health Plan | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 65280IL0010001-00 | ||||||||||||||||||
Provider Network(s) | ['ILN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 65280IL0010001-00 Standard On Exchange Plan - 65280IL0010001-01 |
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Last Plan Update Date | Fri, 24 Feb 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
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; cervical pillows; spinal decompression devices. |
YES | $30.00 |
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 | 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; 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 or covered under our medical policy for a specific condition 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. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
|
YES | $15.00 |
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 | $30.00 |
100.00% |
Hearing Aids
Limit: 2.0 Item(s) per 2 Years Exclusions: Batteries and chargers for hearing aids. Hearing aids that can be bought without a prescription and the following: a fully implantable middle ear hearing aid; non-implantable, intraoral bone conduction hearing aid. 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. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
Exclusions: Services or supplies rendered to a surrogate, except that costs for procedures to obtain eggs, sperm, or embryos from the member shall covered if the member chooses to use a surrogate; 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 | $30.00 |
100.00% |
Non-Preferred Brand Drugs
|
YES | $225.00 |
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 | $30.00 |
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 | $30.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
|
YES | $60.00 |
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 | $30.00 |
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. 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; biofeedback (if prior authorization is obtained). 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 | $30.00 |
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; biofeedback (if prior authorization is obtained). 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 | $30.00 |
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 our medical policy); refractive exams related to contact lenses; any fitting of contact lenses (except for fitting of therapeutic contact lenses as defined by our medical policy); refraction aids for low vision and instruction in their use; visual therapy. |
YES | $30.00 |
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 | $60.00 |
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 | $60.00 |
100.00% |
Specialty Drugs
|
YES | $450.00 |
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 | $30.00 |
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 and medically necessary surgical or non-surgical treatment for the correction of temporomandibular disorders (TMD), 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 TMD, when prior authorized by us. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $30.00 |
$30.00 |
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% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.819661929 |
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 | Standard Gold Off Exchange Plan |
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 | 20.00% |
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, 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, Diabetes, Pregnancy |
EHB Percent of Total Premium | 0.9994 |
First Tier Utilization | 100% |
Formulary ID | ILF001 |
Formulary URL | URL |
HIOS Product ID | 65280IL001 |
Import Date | 2/24/2023 20:01 |
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 | No |
Is a Referral Required for Specialist? | Yes |
Issuer ID | 65280 |
Issuer Marketplace Marketing Name | WellFirst Health |
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 | 20.00% |
Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $1,500 |
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 | Gold |
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 | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 65280IL0010001-00 |
Plan Level Exclusions | See policy or plan document for additional excluded services. |
Plan Marketing Name | WellFirst Gold Copay Plus 1500X (Free Virtual Visits & Transportation) |
Plan Type | HMO |
Plan Variant Marketing Name | WellFirst Gold Copay Plus 1500X (Free Virtual Visits & Transportation) |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $2,200 |
SBC Scenario, Having a Baby, Copayment | $10 |
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 | $1,200 |
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 | ILS001 |
Source Name | SERFF |
Specialist Requiring a Referral | All specialty services with the exception of behavioral health and addiction/substance abuse services |
Plan ID | 65280IL0010001 |
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 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $11400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,700 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
---|
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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