Elite PPO Basic - 54965VA0030004 Health Insurance Plan

Dominion National health insurance plan with the Plan ID 54965VA0030004. The plan is called Elite PPO Basic.

Health Insurance Plan ID 54965VA0030004
Health Insurance Plan Year 2022
State Virginia
Health Insurance Issuer Dominion National
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 54965VA0030004-00
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 - 54965VA0030004-00

Standard On Exchange Plan - 54965VA0030004-01

Last Plan Update Date Mon, 16 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Elite PPO Basic Health Insurance Plan Variant 54965VA0030004-00 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 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Low Off Exchange Plan
Dental Only Plan Yes
EHB Apportionment for Pediatric Dental 1
First Tier Utilization 100%
HIOS Product ID 54965VA003
Import Date 8/16/2021 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 $200 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $100 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $100
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 Low
Multiple In Network Tiers No
National Network Yes
Network ID VAN002
Out of Country Coverage Yes
Out of Country Coverage Description Standard Out of Network PPO Benefits
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Standard Out of Network PPO Benefits
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 54965VA0030004-00
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.
Plan Marketing Name Elite PPO Basic
Plan Type PPO
Plan Variant Marketing Name Elite PPO Basic
QHP/Non QHP Both
Service Area ID VAS002
Source Name SERFF
Plan ID 54965VA0030004
State Code VA

Copay & Coinsurance of Elite PPO Basic Health Insurance Plan, 54965VA0030004

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

Frequently Asked Questions(FAQ) about Elite PPO Basic, 54965VA0030004 Health Insurance Plan, 54965VA0030004

  • Does Elite PPO Basic Health Insurance Plan, 54965VA0030004 support Mail Ordering?

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

  • Does (54965VA0030004) Health Insurance Plan, Variant (54965VA0030004-00) have Out Of Country Coverage?

    Yes. Details: Standard Out of Network PPO Benefits

    Does (54965VA0030004) Health Insurance Plan, Variant (54965VA0030004-00) have Out of Service Area Coverage?

    Yes. Details: Standard Out of Network PPO Benefits

 

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