Elite PPO Premium - 67775DE0020006 Health Insurance Plan

Dominion Dental Services, Inc. health insurance plan with the Plan ID 67775DE0020006. The plan is called Elite PPO Premium.

Health Insurance Plan ID 67775DE0020006
Health Insurance Plan Year 2023
State Delaware
Health Insurance Issuer Dominion Dental Services, Inc.
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 67775DE0020006-00
Provider Network(s) ['DEN002']
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 Delaware 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 - 67775DE0020006-00

Standard On Exchange Plan - 67775DE0020006-01

Last Plan Update Date Thu, 18 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Elite PPO Premium Health Insurance Plan, 67775DE0020006-00

Benefit Covered In Network Out Of Network
Accidental Dental
NO
Basic Dental Care - Adult

Limit: 1.0 Procedure(s) per 2 Years

YES

20.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Basic Dental Care - Child

Limit: 1.0 Procedure(s) per 2 Years

YES

20.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

0.00%

20.00%
Major Dental Care - Adult

Limit: 84.0 Months per Procedure

YES

50.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Major Dental Care - Child

Limit: 60.0 Months per Procedure

YES

50.00% Coinsurance after deductible

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

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

YES

0.00%

10.00%

Elite PPO Premium Health Insurance Plan Variant 67775DE0020006-00 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 67775DE002
Import Date 8/18/2022 20:01
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 67775
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 $100 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $50 per person
Medical EHB Deductible, In Network (Tier 1), Individual $50
Medical EHB Deductible, Out of Network, Family Per Group $100 per group
Medical EHB Deductible, Out of Network, Family Per Person $50 per person
Medical EHB Deductible, Out of Network, Individual $50
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 Yes
Network ID DEN002
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 67775DE0020006-00
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 Premium
Plan Type PPO
Plan Variant Marketing Name Elite PPO Premium
QHP/Non QHP Both
Service Area ID DES002
Source Name SERFF
Plan ID 67775DE0020006
State Code DE

Copay & Coinsurance of Elite PPO Premium Health Insurance Plan, 67775DE0020006

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

Frequently Asked Questions(FAQ) about Elite PPO Premium, 67775DE0020006 Health Insurance Plan, 67775DE0020006

  • Does Elite PPO Premium Health Insurance Plan, 67775DE0020006 support Mail Ordering?

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

  • Does (67775DE0020006) Health Insurance Plan, Variant (67775DE0020006-00) have Out Of Country Coverage?

    Yes. Details: Standard Out of Network PPO Benefits

    Does (67775DE0020006) Health Insurance Plan, Variant (67775DE0020006-00) 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