Elite ePPO Premium - 54965VA0070002 Health Insurance Plan

Dominion National health insurance plan with the Plan ID 54965VA0070002. The plan is called Elite ePPO Premium.

Health Insurance Plan ID 54965VA0070002
Health Insurance Plan Year 2023
State Virginia
Health Insurance Issuer Dominion National
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 54965VA0070002-00
Provider Network(s) ['VAN002']
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 Virginia 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 - 54965VA0070002-00

Standard On Exchange Plan - 54965VA0070002-01

Last Plan Update Date Thu, 15 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Elite ePPO Premium Health Insurance Plan, 54965VA0070002-00

Benefit Covered In Network Out Of Network
Accidental Dental
YES

34.00%

100.00%
Basic Dental Care - Adult

Subject to deductible of $25/individual and $75/three or more adults for In Network Services Only. Adult dental annual maximum of $1500 applies to Class 1, 2 and 3. Benefit limitations may apply to individual services.

YES

34.00%

100.00%
Basic Dental Care - Child

Benefit limitations may apply to individual services. Max Out of Pocket is $375 per child up to $750 per family

YES

20.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

1 per 6 months Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208.

YES

0.00%

20.00%
Major Dental Care - Adult

Subject to deductible of $25/individual and $75/three or more adults for In Network Services Only. Adult dental annual maximum of $1500 applies to Class 1, 2 and 3. Benefit limitations may apply to individual services.

YES

47.00%

100.00%
Major Dental Care - Child

Benefit limitations may apply to individual services.

YES

50.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child

Limit: 1.0 Treatment(s) per Lifetime

Limit applies to one comprehensive orthodontic treatment of the adolescent dentition. Orthodontia services are only provided for severe, dysfunctional, handicapping maloclussion.

YES

50.00%

100.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

Adult dental annual maximum of $1500 applies to Class 1, 2 and 3. Benefit limitations may apply to individual services. Benefit includes 2 visits per year.

YES

18.00%

100.00%

Elite ePPO Premium Health Insurance Plan Variant 54965VA0070002-00 Attributes

Plan Attribute Value
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 High Off Exchange Plan
Dental Only Plan Yes
EHB Apportionment for Pediatric Dental 1
First Tier Utilization 100%
HIOS Product ID 54965VA007
Import Date 9/15/2022 20:01
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 54965
Issuer Marketplace Marketing Name Dominion National
Market Coverage Individual
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Not Applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Group $100 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $50 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $50
Medical EHB Deductible, In Network (Tier 1), Family Per Group per group not applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Person per person not applicable
Medical EHB Deductible, In Network (Tier 1), Individual Not Applicable
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
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group $750 per group
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person $375 per person
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual $375
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual Not Applicable
Metal Level High
Multiple In Network Tiers No
National Network No
Network ID VAN002
Out of Country Coverage Yes
Out of Country Coverage Description Emergency pain treatment only if 50 miles away from home zip code, up to $100
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency pain treatment only if 50 miles away from home zip code, up to $100
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 54965VA0070002-00
Plan Level Exclusions Out of Pocket Maximum applies to children only. Adults have separate deductible and plan payment maximum, refer to plan document for details. Co-insurance equivalent percentages displayed except for orthodontic services; copay for orthodontic services will not equal more than out of pocket maximum.
Plan Marketing Name Elite ePPO Premium
Plan Type PPO
Plan Variant Marketing Name Elite ePPO Premium
QHP/Non QHP Both
Service Area ID VAS002
Source Name SERFF
Plan ID 54965VA0070002
State Code VA

Copay & Coinsurance of Elite ePPO Premium Health Insurance Plan, 54965VA0070002

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

Frequently Asked Questions(FAQ) about Elite ePPO Premium, 54965VA0070002 Health Insurance Plan, 54965VA0070002

  • Does Elite ePPO Premium Health Insurance Plan, 54965VA0070002 support Mail Ordering?

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

  • Does (54965VA0070002) Health Insurance Plan, Variant (54965VA0070002-00) have Out Of Country Coverage?

    Yes. Details: Emergency pain treatment only if 50 miles away from home zip code, up to $100

    Does (54965VA0070002) Health Insurance Plan, Variant (54965VA0070002-00) have Out of Service Area Coverage?

    Yes. Details: Emergency pain treatment only if 50 miles away from home zip code, up to $100

 

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