Elite PPO Preventive - 54965VA0030008 Health Insurance Plan

Dominion National health insurance plan with the Plan ID 54965VA0030008. The plan is called Elite PPO Preventive.

Health Insurance Plan ID

54965VA0030008

Health Insurance Plan Year

2023

State

Virginia

Health Insurance Issuer

Dominion National

Plan Marketing Materials URL

Marketing URL

Health Insurance Plan Variant

54965VA0030008-00

Provider Network(s)

['VAN002']

In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 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 - 54965VA0030008-00

Standard On Exchange Plan - 54965VA0030008-01

Last Plan Update Date

Thu, 15 Sep 2022 00:00 GMT

Last Import Date

Tue, 16 Apr 2024 06:19 GMT

Benefits of Elite PPO Preventive Health Insurance Plan, 54965VA0030008-00

Benefit	Covered	In Network	Out Of Network
Accidental Dental	YES	0.00% Coinsurance after deductible	20.00% Coinsurance after deductible
Basic Dental Care - Adult	NO
Basic Dental Care - Child Benefit limitations may apply to individual services. Max Out of Pocket is $375per child up to $750 per family	YES	65.00% Coinsurance after deductible	80.00% 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	100.00%	80.00%
Major Dental Care - Adult	NO
Major Dental Care - Child Benefit limitations may apply to individual services.	YES	75.00% Coinsurance after deductible	90.00% 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 Subject to deductible of $50/individual and $150/three or more adults. Benefit limitations may apply to individual services. Benefit includes 2 visits per year.	YES	0.00% Coinsurance after deductible	20.00% Coinsurance after deductible

Elite PPO Preventive Health Insurance Plan Variant 54965VA0030008-00 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 Low Off Exchange Plan
Dental Only Plan	Yes
EHB Apportionment for Pediatric Dental	1
First Tier Utilization	100%
HIOS Product ID	54965VA003
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	$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	1/1/2023
Plan Expiration Date	12/31/2023
Plan ID (Standard Component ID with Variant)	54965VA0030008-00
Plan Marketing Name	Elite PPO Preventive
Plan Type	PPO
Plan Variant Marketing Name	Elite PPO Preventive
QHP/Non QHP	Both
Service Area ID	VAS002
Source Name	SERFF
Plan ID	54965VA0030008
State Code	VA

Copay & Coinsurance of Elite PPO Preventive Health Insurance Plan, 54965VA0030008

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

Frequently Asked Questions(FAQ) about Elite PPO Preventive, 54965VA0030008 Health Insurance Plan, 54965VA0030008

Does Elite PPO Preventive Health Insurance Plan, 54965VA0030008 support Mail Ordering?

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

Does (54965VA0030008) Health Insurance Plan, Variant (54965VA0030008-00) have Out Of Country Coverage?

Yes. Details: Standard Out of Network PPO Benefits

Does (54965VA0030008) Health Insurance Plan, Variant (54965VA0030008-00) have Out of Service Area Coverage?