Dean Silver Copay Elite 4800X - 38345WI0010157 Health Insurance Plan

Dean Health Plan health insurance plan with the Plan ID 38345WI0010157. The plan is called Dean Silver Copay Elite 4800X.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.79% (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 28.21% 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 38345WI0010157
Health Insurance Plan Year 2022
State Wisconsin
Health Insurance Issuer Dean Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 38345WI0010157-00
Provider Network(s) ['WIN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 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 - 38345WI0010157-00

Standard On Exchange Plan - 38345WI0010157-01

Open to Indians below 300% FPL - 38345WI0010157-02

Open to Indians above 300% FPL - 38345WI0010157-03

73% AV Silver Plan - 38345WI0010157-04

87% AV Silver Plan - 38345WI0010157-05

94% AV Silver Plan - 38345WI0010157-06

Last Plan Update Date Sat, 17 Jul 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Dean Silver Copay Elite 4800X Health Insurance Plan Variant 38345WI0010157-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.717887119
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver 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 30.00%
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 30.00%
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
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 45%
Formulary ID WIF001
Formulary URL URL
HIOS Product ID 38345WI001
Import Date 7/17/2021 1:02
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 38345
Issuer Marketplace Marketing Name Dean Health Plan
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 30.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $9600 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $4800 per person
Medical EHB Deductible, In Network (Tier 1), Individual $4,800
Medical EHB Deductible, In Network (Tier 2), Default Coinsurance 30.00%
Medical EHB Deductible, In Network (Tier 2), Family Per Group $9600 per group
Medical EHB Deductible, In Network (Tier 2), Family Per Person $4800 per person
Medical EHB Deductible, In Network (Tier 2), Individual $4,800
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 WIN001
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 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 38345WI0010157-00
Plan Level Exclusions See policy or plan document for additional excluded services.
Plan Marketing Name Dean Silver Copay Elite 4800X
Plan Type HMO
Plan Variant Marketing Name Dean Silver Copay Elite 4800X
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,300
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $4,800
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $600
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 55%
Service Area ID WIS006
Source Name HIOS
Plan ID 38345WI0010157
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,700
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

Copay & Coinsurance of Dean Silver Copay Elite 4800X Health Insurance Plan, 38345WI0010157

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

Frequently Asked Questions(FAQ) about Dean Silver Copay Elite 4800X, 38345WI0010157 Health Insurance Plan, 38345WI0010157

  • Does Dean Silver Copay Elite 4800X Health Insurance Plan, 38345WI0010157 support Mail Ordering?

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

  • Does (38345WI0010157) Health Insurance Plan, Variant (38345WI0010157-00) offer Disease Management Programs?

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

    Does (38345WI0010157) Health Insurance Plan, Variant (38345WI0010157-00) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (38345WI0010157) Health Insurance Plan, Variant (38345WI0010157-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

    Does (38345WI0010157) Health Insurance Plan, Variant (38345WI0010157-00) offer Disease Management Programs?

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

    Does Dean Silver Copay Elite 4800X Health Insurance Plan, Variant (38345WI0010157-00) offer Disease Management Programs for Asthma?

    Yes, the Dean Silver Copay Elite 4800X Health Insurance Plan Variant 38345WI0010157-00 offers Disease Management Program for Asthma.

    Does Dean Silver Copay Elite 4800X Health Insurance Plan, Variant (38345WI0010157-00) offer Disease Management Programs for Heart disease?

    Yes, the Dean Silver Copay Elite 4800X Health Insurance Plan Variant 38345WI0010157-00 offers Disease Management Program for Heart disease.

    Does Dean Silver Copay Elite 4800X Health Insurance Plan, Variant (38345WI0010157-00) offer Disease Management Programs for Diabetes?

    Yes, the Dean Silver Copay Elite 4800X Health Insurance Plan Variant 38345WI0010157-00 offers Disease Management Program for Diabetes.

    Does Dean Silver Copay Elite 4800X Health Insurance Plan, Variant (38345WI0010157-00) offer Disease Management Programs for Pregnancy?

    Yes, the Dean Silver Copay Elite 4800X Health Insurance Plan Variant 38345WI0010157-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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